Sphere Handbook 2018 en

The
Sphere
Handbook
Humanitarian Charter and Minimum Standards

in Humanitarian Response
What is sphere?
THE Humanitarian Charter
Protection Principles
Core Humanitarian Standard
Water SUPPLY, Sanitation and Hygiene Promotion
Food Security and Nutrition
Shelter and Settlement
Health
Sphere Association
3 Rue de Varembé
1202 Geneva, Switzerland
Email: [email protected]
Website: www.spherestandards.org
First edition 2000

Second edition 2004
Third edition 2011
Fourth edition 2018
Copyright © Sphere Association, 2018

Copyright for the Core Humanitarian Standard on Quality and Accountability © CHS Alliance,
Sphere Association and Groupe URD, 2018
All rights reserved. This material is copyrighted but may be reproduced without fee for
educational purposes, including for training, research and programme activities, provided
that the copyright holder is acknowledged. It is not intended for resale. For copying in other
circumstances, posting online, reuse in other publications or for translation or adaptation,
prior written permission must be obtained by emailing [email protected].
A catalogue record for this publication is available from The British Library and the US Library
of Congress.
ISBN 978-1-908176-400 PBK

ISBN 978-1-908176-608 EPUB
ISBN 978-1-908176-707 PDF
Citation: Sphere Association. The Sphere Handbook: Humanitarian Charter and Minimum
Standards in Humanitarian Response, fourth edition, Geneva, Switzerland, 2018.
www.spherestandards.org/handbook
The Sphere Project was initiated in 1997 by a group of NGOs and the Red Cross and Red
Crescent Movement to develop a set of universal minimum standards in core areas of
humanitarian response: The Sphere Handbook. The aim of the Handbook is to improve the
quality of humanitarian response in situations of disaster and conflict, and to enhance the
accountability of humanitarian action to crisis-affected people. The Humanitarian Charter
and Minimum Standards in Humanitarian Response are the product of the collective
experience of many people and agencies. They should therefore not be seen as represent-
ing the views of any one agency. In 2016, the Sphere Project was registered as the Sphere
Association.
Distributed for the Sphere Association by Practical Action Publishing and its agents and
representatives throughout the world. Practical Action Publishing (UK Company Reg. No.
1159018) is the wholly owned publishing company of Practical Action and trades only in
support of its parent charity objectives.
Practical Action Publishing, 27a, Albert Street, Rugby, CV21 2SG, United Kingdom
Tel +44 (0) 1926 634501; Fax +44 (0)1926 634502
Website: www.practicalactionpublishing.org/sphere
Designed by: Non-linear Design Studio, Milan, Italy

Printed by: Shortrun Press, United Kingdom.
Typeset by vPrompt eServices, India
Contents
Foreword............................................................................................................................................v
Acknowledgements..................................................................................................................... vii
What is Sphere?...............................................................................................................................1
The Humanitarian Charter........................................................................................................ 27
Protection Principles.................................................................................................................. 33
Core Humanitarian Standard................................................................................................... 49
Water Supply, Sanitation and Hygiene Promotion...........................................................89
Food Security and Nutrition................................................................................................... 157
Shelter and Settlement........................................................................................................... 237
Health............................................................................................................................................ 289
Annexes......................................................................................................................................... 371
Annex 1: Legal Foundation to Sphere............................................................................ 374
Annex 2: Code of Conduct.................................................................................................. 385
Annex 3: Abbreviations and Acronyms......................................................................... 393
Index............................................................................................................................................... 395
iii
Foreword
The Sphere Handbook is marking its 20th anniversary with the publication of
this fourth edition. It is the result of an intense year-long mobilisation of human-
itarian actors around the globe and reflects two decades of experience using the
standards in front-line operations, policy development and advocacy to uphold
principled quality and accountability.
With a clear, rights-based framework, the Handbook builds on the legal and
ethical foundations of humanitarianism with pragmatic guidance, global
good practice and compiled evidence to support humanitarian staff wherever
they work.
Sphere holds a unique place in the sector and in the constantly evolving human-
itarian landscape. This edition was clearly informed by the international commit-
ments made at the first World Humanitarian Summit in 2016, the 2030 Agenda for
Sustainable Development and other global initiatives.
However, even as the policy landscape continues to evolve, we know that the
immediate survival needs of people in conflict and disasters remain largely
the same wherever crisis strikes. Sphere supports and contributes to global
and local policy processes by recalling the fundamental necessity to provide
accountable assistance to help people survive, recover and rebuild their lives
with dignity.
Sphere’s strength and global reach lie in the fact that it belongs to all. This
sense of ownership is renewed every few years, when the standards are
reviewed and revised by the users themselves. It is a moment when we collec-
tively restate our commitments and agree on improved action to make sure
that practitioners have the best information available to them wherever they
may work. This makes Sphere a core reference and a reminder of the funda-
mental importance of human dignity and the right of people to participate fully
in decisions that affect them.
Sphere is one of the foundations of humanitarian work. It is the starting point for
new humanitarian actors and a standing reference for experienced staff, providing
guidance on priority actions and where to find more detailed technical information.
Our standards partners provide even more support in specific sectors beyond
Sphere to help people recover and thrive.
This edition benefits from the input of thousands of people working with more
than 450 organisations in at least 65 countries around the world. The global reach
reflects experience from diverse contexts, extraordinary challenges and different
v
Foreword
types of actors. These standards would not exist without the unwavering commit-
ment of so many of you. You have the thanks of our sector for your contributions
during the revision and, indeed, over the past two decades.
We look forward to continuing this important work and learning together with you
as you use this Handbook.
Martin McCann Christine Knudsen

Sphere Board Chair Executive Director
vi
Acknowledgements
This edition of The Sphere
Handbook is the result of the The Shelter and Settlement chapter
most diverse and far-reaching is dedicated to the memory of Graham
consultation process in the Saunders, author of this chapter
history of Sphere. Nearly 4,500 in the 2004 and 2011 editions and
online comments were received advisor in the early development of
from 190 organisations, and more the 2018 edition.
than 1,400 people participated in Graham was a true humanitarian and
60 in-person events hosted by a champion of the Shelter sector. His
partners in 40 countries. Sphere vision, leadership and endless energy
gratefully acknowledges the have been instrumental in putting
scale and breadth of the contri- humanitarian shelter issues on the
butions made, including from map and shaping the field for future
national, local and international generations of shelter practitioners.
NGOs, national authorities and He continuously strived to improve
ministries, Red Cross and Red our practice and professionalise the
Crescent societies, universities, sector. He will be greatly missed as a
UN organisations and individual pioneer, professional and friend.
practitioners.
The revision process was coordinated by the Sphere office. Individual chapters
were developed by lead authors with cross-sectoral support from desig-
nated thematic experts and resource persons from the humanitarian sector.
The majority of the authors and thematic experts were put forward by their
home organisations, dedicating their time and effort as an in-kind contribution
to the sector.
Writing groups and reference groups were established to support the authors
and thematic experts in their work. Sphere acknowledges the valuable contribu-
tion of all these individuals throughout 2017 and 2018. A full list of all working
group and reference group members can be found on the Sphere website,
spherestandards.org. Lead authors and experts are noted below.
Foundation chapters
•• Humanitarian Charter and Annex 1: Dr Mary Picard
•• Protection Principles: Simon Russell (Global Protection Cluster) and Kate
Sutton (Humanitarian Advisory Group)
•• Core Humanitarian Standard: Takeshi Komino (CWSA Japan) and Sawako
Matsuo (JANIC)
vii
Acknowledgements
Technical chapters
•• Water, Sanitation and Hygiene Promotion: Kit Dyer (NCA) and Jenny Lamb
(Oxfam GB)
•• Food Security: Daniel Wang’ang’a (WVI)
•• Nutrition: Paul Wasike (Save the Children USA)
•• Shelter and Settlement: Seki Hirano (CRS) and Ela Serdaroglu (IFRC)
•• Health: Dr Durgavasini Devanath (IFRC), Dr Julie Hall (IFRC), Dr Judith Harvie
(International Medical Corps), Dr Unni Krishnan (Save the Children Australia),
Dr Eba Pasha (independent)
Vulnerabilities, capacities and operational settings

•• Children and child protection: Susan Wisniewski (Terre des Hommes)
•• Older people: Irene van Horssen and Phil Hand (HelpAge)
•• Gender: Mireia Cano (GenCap)
•• Gender-based violence: Jeanne Ward (independent)
•• Persons with disabilities: Ricardo Pla Cordero (Humanity and Inclusion)
•• People living with and affected by HIV: Alice Fay (UNHCR)
•• Mental health and psychosocial support: Dr Mark van Ommeren (WHO),
Peter Ventevogel (UNHCR)
•• Protracted crises: Sara Sekkenes (UNDP)
•• Urban settings: Pamela Sitko (WVI)
•• Civil–military coordination: Jennifer Jalovec and Mark Herrick (WVI)
•• Environment: Amanda George and Thomas Palo (Swedish Red Cross)
•• Disaster risk reduction: Glenn Dolcemascolo and Muthoni Njogu (UNISDR)
•• Cash-based assistance and markets: Isabelle Pelly (CaLP)
•• Supply-chain management and logistics: George Fenton (Humanitarian
Logistics Association)
•• Monitoring, evaluation, accountability and learning: Joanna Olsen (CRS)
Sphere Board (May 2018)

Action by Churches Together (ACT) Alliance (Alwynn Javier) * Aktion Deutschland
Hilft (ADH) (Karin Settele) * CARE International (Phillipe Guiton) * CARITAS
Internationalis (Jan Weuts) * Humanitarian Response Network, Canada (Ramzi
Saliba) * InterAction (Julien Schopp) * The International Council of Voluntary
Agencies (ICVA) (Ignacio Packer) * International Federation of Red Cross and Red
Crescent Societies (IFRC) (David Fisher) * International Medical Corps (IMC) (Mary
Pack) * The Lutheran World Federation (LWF) (Roland Schlott) * Office Africain
pour le développement et la coopération (OFADEC) (Mamadou Ndiaje) * Oxfam
International - Intermón (Maria Chalaux Freixa) * Plan International (Colin Rogers) *
RedR International (Martin McCann) * Save the Children (Unni Krishnan) * Sphere
India (Vikrant Mahajan) * The Salvation Army (Damaris Frick) * World Vision
International (WVI) (Isabel Gomes).
viii
Acknowledgements
Thanks also go to Board members who initiated and guided the revision have
since left the Board: Sarah Kambarami (ACT Alliance) * Anna Garvander (Church
of Sweden/LWF) * Nan Buzard (ICVA) * Barbara Mineo (Oxfam International –
Intermón) * Maxime Vieille (Save the Children).
Donors
In addition to contributions from the Board organisations listed above, funding for
the Handbook revision process was provided by:
Danish International Development Agency (DANIDA) * German Ministry of Foreign
Affairs * Irish Aid * Australian Government – Department of Foreign Affairs and
Trade (DFAT) * European Commission’s Humanitarian Aid and Civil Protection
Department (ECHO) through International Federation of Red Cross and Red Crescent
Societies (IFRC) * USAID’s Office of United States Foreign Disaster Assistance
(OFDA) * Swedish International Development Cooperation Agency (SIDA) through
Church of Sweden * Swiss Agency for Development and Cooperation (SDC) * United
Nations High Commissioner for Refugees (UNHCR) * United States Department of
State Bureau of Population, Refugees and Migration (US-PRM).
Handbook revision team

Christine Knudsen, Executive Director (Sphere)
Aninia Nadig, Advocacy and Networking Manager (Sphere)
Editors: Kate Murphy and Aimee Ansari (Translators without Borders)
Revision coordinators: Lynnette Larsen and Miro Modrusan
With support from Sphere staff:
Tristan Hale, Learning and Training Manager
Wassila Mansouri, Networking and Outreach Officer
Juan Michel, Communications Manager through September 2017
Barbara Sartore, Communications Manager from October 2017
Loredana Serban, Administration and Finance Officer
Kristen Pantano and Caroline Tinka, Interns
Online consultation support: Markus Forsberg, (PHAP)
Handbook design: Non-linear (www.non-linear.com)
Copy editing, layout and production: Practical Action Publishing
(www.practicalactionpublishing.org)
Kimberly Clarke and Megan Lloyd-Laney (CommsConsult)
Significant thanks for additional support during the Handbook revision
process go to James Darcy, Malcolm Johnston, Hisham Khogali, Ben Mountfield,
Dr Alice Obrecht, Ysabeau Rycx, Panu Saaristo, Manisha Thomas and Marilise
Turnbull.
ix
Acknowledgements
Sphere Focal Points which organised in-person revision

consultations:
ADRA Argentina (Regional consultation with ADRAs South America)
Agency Coordinating Body for Afghan Relief (Afghanistan)
Alliance of Sphere Advocates in the Philippines (ASAP)
Amity Foundation (member of The Benevolence Standards Working Group, Focal
Point for China)
BIFERD (Democratic Republic of Congo)
Community World Service Asia (Thailand and Pakistan)
Daniel Arteaga Galarza* with Secretaría de Gestión de Riesgos (Ecuador)
Dr Oliver Hoffmann* with the Sphere Focal Point for Germany
Grupo Esfera Bolivia
Grupo Esfera El Salvador
Grupo Esfera Honduras
Illiassou Adamou* with the Child Protection sub-cluster (Niger)
Indonesian Society for Disaster Management (MPBI)
Institut Bioforce (France)
InterAction (United States)
Inter-Agency Accountability Working Group (Ethiopia)
Korea NGO Council for Overseas Development Cooperation (Korea, Republic of)
Sphere Community Bangladesh (SCB)
Sphere India
Ukraine NGO Forum
UNDP Chile
*Individual focal points
x
What is Sphere? – The Handbook
What is
Sphere?
1
Handbook
What is Sphere?
PRINCIPLES + FOUNDATIONS
Humanitarian
Charter
Protection Core
Principles Humanitarian
Standard
Water Supply, Food Security Shelter and Health

Sanitation and and Nutrition Settlement
Hygiene
Promotion
STANDARDS
ANNEX 1 Legal foundation to Sphere

ANNEX 2 Code of Conduct
ANNEX 3 Acronyms and Abbreviations
2
Contents
What is Sphere?............................................................................................................................... 4
1. The Handbook........................................................................................................................ 4
Four foundation chapters and four technical chapters......................................... 5
The Minimum Standards promote a consistent approach................................... 6
The structure of the standards..................................................................................... 6
Working with the key indicators.................................................................................... 7
Links with other standards............................................................................................. 7
2. Using the standards in context........................................................................................ 8
The standards apply throughout the programme cycle.............................................. 9
Assessment and analysis................................................................................................ 9
Strategy development and programme design....................................................... 9
Implementation................................................................................................................10
Monitoring, evaluation, accountability and learning............................................10
Understanding vulnerabilities and capacities...............................................................10
Data disaggregation........................................................................................................ 12
Children................................................................................................................................ 12
Older people....................................................................................................................... 13
Gender.................................................................................................................................. 13
Gender-based violence................................................................................................... 14
Persons with disabilities................................................................................................ 14
People living with and affected by HIV..................................................................... 15
LGBTQI people................................................................................................................... 15
Mental health and psychosocial support................................................................. 15
Understanding the operational setting........................................................................... 16
Supporting national and local actors......................................................................... 16
Protracted crises.............................................................................................................. 17
Urban settings................................................................................................................... 17
Communal settlements.................................................................................................18
Settings with domestic or international military forces.....................................18
Environmental impact in humanitarian response................................................. 19
Appendix: Delivering assistance through markets..........................................................20
References and further reading...............................................................................................26
3
What is Sphere?
What is Sphere?
The Sphere Project, now known as Sphere, was created in 1997 by a group of
humanitarian non-governmental organisations and the Red Cross and Red
Crescent Movement. Its aim was to improve the quality of their humanitarian
responses and to be accountable for their actions. The Sphere philosophy is based
on two core beliefs:
•• People affected by disaster or conflict have the right to life with dignity and,
therefore, the right to assistance; and
•• All possible steps should be taken to alleviate human suffering arising out of
disaster or conflict.
The Humanitarian Charter and Minimum Standards put these core beliefs into
practice. The Protection Principles inform all humanitarian action, and the Core
Humanitarian Standard contains commitments to support accountability across
all sectors. Together, they form The Sphere Handbook, which has developed into
one of the most widely referenced humanitarian resources globally.
1. The Handbook
The principal users of The Sphere Handbook are practitioners involved in planning,
managing or implementing a humanitarian response. This includes staff and volun-
teers of local, national and international humanitarian organisations responding
to a crisis, as well as affected people themselves. The Handbook is also used for
humanitarian advocacy to improve the quality and accountability of assistance and
protection in line with humanitarian principles. It is increasingly used by govern-
ments, donors, military or the private sector to guide their own actions and allow
them to work constructively with the humanitarian organisations that apply the
standards.
The Handbook was first piloted in 1998, with revised editions published in
2000, 2004, 2011 and now 2018. Each revision process has relied on sector-
wide consultations with individuals, non-governmental organisations (NGOs),
governments and United Nations agencies. The resulting standards and guidance
are informed by evidence and reflect 20 years of field testing by practitioners
around the world.
This fourth edition marks the 20th anniversary of The Sphere Handbook and
reflects changes in the humanitarian sector over that time. It includes new
guidance for working in urban settings, for addressing Minimum Standards in
protracted crises, and for delivering assistance through markets as a way to meet
the standards. All technical chapters have been updated to reflect current
practice, and the harmonised Core Humanitarian Standard replaces the previous
Core Standards.
4
Four foundation chapters and four technical chapters

The Handbook reflects Sphere’s commitment to a principled and rights-based
humanitarian response. It is based on fundamental respect for people’s right to be
fully involved in decisions regarding their recovery.
The four foundation chapters outline the ethical, legal and practical basis for
humanitarian response. They underpin all technical sectors and programmes.
They describe commitments and processes to ensure a good quality humani-
tarian response, and encourage responders to be accountable to those affected
by their actions. These chapters help the user apply the Minimum Standards
more effectively in any context. Reading a technical chapter without also read-
ing the foundation chapters risks missing essential elements of the standards.
The foundation chapters are:
What is Sphere? (this chapter): Outlines the Handbook structure, its use and
underlying principles. Importantly, it illustrates how to use the Handbook
in practice.
The Humanitarian Charter: The cornerstone of The Sphere Handbook, express-
ing the shared conviction of humanitarian actors that all people affected by crisis
have a right to receive protection and assistance. This right ensures the basic
conditions for life with dignity. The Charter provides the ethical and legal backdrop
to the Protection Principles, the Core Humanitarian Standard and the Minimum
Standards. It builds on the 1994 Code of Conduct for the International Red Cross
and Red Crescent Movement and Non-Governmental Organisations (NGOs) in
Disaster Relief. The Code of Conduct remains an integral component of The Sphere
Handbook ⊕ see Annex 2.
For a list of key documents constituting the legal foundation to the Humanitarian
Charter ⊕ see Annex 1.
Protection Principles: A practical translation of the legal principles and rights
outlined in the Humanitarian Charter into four principles that inform all humani-
tarian response.
The Core Humanitarian Standard: Nine commitments that describe essential
processes and organisational responsibilities to enable quality and accountability
in achieving the Minimum Standards.
The four technical chapters include Minimum Standards in key response sectors:
•• Water Supply, Sanitation and Hygiene Promotion (WASH)

•• Food Security and Nutrition
•• Shelter and Settlement
•• Health
In practice, humanitarian needs do not fall neatly into specific sectors. Effective
humanitarian response must address people’s needs holistically, and sectors
should coordinate and collaborate with each other to do so. In the context of a
5
What is Sphere?
The Code of Conduct: 10 Core Principles
1. The humanitarian imperative comes first.

2. Aid is given regardless of the race, creed or nationality of the recipients and
without adverse distinction of any kind. Aid priorities are calculated on the basis
of need alone.
3. Aid will not be used to further a particular political or religious standpoint.
4. We shall endeavour not to act as instruments of government foreign policy.
5. We shall respect culture and custom.
6. We shall attempt to build disaster response on local capacities.
7. Ways shall be found to involve programme beneficiaries in the management of
relief aid.
8. Relief aid must strive to reduce future vulnerabilities to disaster as well as
meeting basic needs.
9. We hold ourselves accountable to both those we seek to assist and those from
whom we accept resources.
10. In our information, publicity and advertising activities, we shall recognise disaster
victims as dignified human beings, not hopeless objects.
The Code of Conduct: Principles of Conduct for the International Red Cross and Red Crescent Movement
and NGOs in Disaster Response Programmes for full text ⊕ see Annex 2
protracted crisis, this may also expand beyond the humanitarian response
with a need to work closely with development actors. The Handbook contains
cross-references to help make these links. Readers should familiarise them-
selves with all chapters to support a holistic response.
The Minimum Standards promote a consistent approach

The standards are informed by available evidence and humanitarian experience.
They present best practice based on broad consensus. Because they reflect
inalienable human rights, they apply universally.
However, the context in which a response is taking place must be understood,
monitored and analysed in order to apply the standards effectively.
The structure of the standards

The standards share a common structure to support the reader in understanding
the universal statement, followed by a series of key actions, key indicators and
guidance notes to achieve them.
•• The standards are derived from the principle of the right to life with dignity.
These are general and qualitative in nature, stating the minimum to be
achieved in any crisis. The equivalents in the Core Humanitarian Standard
(CHS) are the “commitment” and “quality criterion”.
•• Key actions outline practical steps to attain the Minimum Standard. These
are suggestions and may not be applicable in all contexts. The practitioner
should select the most relevant for the situation.
6
•• Key indicators serve as signals to measure whether the standard is

being attained. They provide a way to capture process and programme
results against the standard and over the life of the response. Minimum
quantitative requirements are the lowest acceptable level of achieve-
ment for indicators and are only included where there is sectoral
consensus.
•• Guidance notes provide additional information to support the key actions,
with cross-references to the Protection Principles, the Core Humanitarian
Standard and other standards within the Handbook. Cross-references
are also given to other standards of the Humanitarian Standards
Partnership.
Working with the key indicators

The Sphere key indicators are a way to measure whether a standard is being
achieved; they should not be confused with the standard itself. The standard is
universal, but the key indicators, like the key actions, should be considered in
light of both the context and phase of the response. There are three types of
Sphere indicator:
•• Process indicators check whether a minimum requirement has been

achieved. For example: standardised protocols are used to analyse food
security, livelihoods and coping strategies ⊕ see Food security and nutrition
assessments standard 1.1: Food security assessment.
•• Progress indicators provide the unit of measurement to monitor
achievement of the standard. It should be used to determine baseline,
set targets with partners and stakeholders, and monitor changes
towards that target. For example: percentage of households observed
to store water safely in clean and covered containers at all times ⊕ see
Water supply standard 2.2: Water quality. While the optimal target is 100
per cent, practitioners should associate the indicator with the reality on
the ground, monitoring improvements against the baseline and progress
towards the agreed target over time.
•• Target indicators are specific, quantifiable targets which represent the
quantifiable minimum below which the standard is not being met. Those
targets should be reached as soon as possible, as falling short of the target
will compromise the overall programme. For example: percentage of children
aged six months to 15 years who have received measles vaccination: target
is 95 per cent ⊕ see Essential healthcare – child health standard 2.2.1: Childhood
vaccine-preventable diseases.
Links with other standards

The Sphere Handbook does not cover all aspects of humanitarian assistance
that support the right to life with dignity. Partner organisations have devel-
oped complementary standards in several sectors, based on the same philos-
ophy and commitments as Sphere’s. These are available through Sphere,
7
What is Sphere?
the Humanitarian Standards Partnership and their partner organisations’

own websites.
•• Livestock Emergency Guidelines and Standards (LEGS): LEGS Project

•• Minimum Standards for Child Protection in Humanitarian Action (CPMS):
Alliance for Child Protection in Humanitarian Action
•• Minimum Standards for Education: Preparedness, Response, Recovery:
Inter-Agency Network for Education in Emergencies (INEE)
•• Minimum Economic Recovery Standards (MERS): Small Enterprise Education
and Promotion (SEEP) Network
•• Minimum Standard for Market Analysis (MISMA): Cash Learning
Partnership (CaLP)
•• Humanitarian Inclusion Standards for Older People and People with
Disabilities: Age and Disability Consortium
2. Using the standards in context

Humanitarian responses take place in many different contexts. Several factors will
influence how the Minimum Standards can be applied in the operating environ-
ment to support the right to life with dignity. These factors include:
•• the setting in which humanitarian response is being delivered;

•• the differences across populations and diversity among individuals;
•• operational and logistical realities that will affect how and what kind of
humanitarian response is delivered; and
•• accurate baselines and indicators in different contexts, including defining key
terms and setting targets.
Culture, language, the capacity of responders, security, access, environmental condi-

tions and resources will influence the response. It is also important to anticipate any
potential negative effects of the response and act to limit these ⊕ see Protection
Principles 1 and 2, and Core Humanitarian Standard Commitment 3.
The Sphere Handbook is a voluntary code for quality and accountability, designed
to encourage the broadest possible use and ownership of the standards. It is not a
“how to” guide but a description of what must be in place as a minimum for people
to survive and recover from crisis with dignity.
Conforming to the Sphere standards does not mean implementing all key actions
or meeting all key indicators of all standards. The degree to which an organisa-
tion can meet the standards will depend on a range of factors, some of which are
beyond their control. Access to the affected population, or political or economic
insecurity, may make achieving the standards impossible in some contexts.
In cases where the minimum requirements exceed the living conditions of the host
community, consider how to reduce potential tension, such as by offering community-
based services. In some situations, national authorities may establish minimum
requirements that are higher than the Sphere Minimum Standards.
8
What is Sphere? – The standards apply throughout the programme cycle
The Sphere standards are an expression of the fundamental rights related to life with
dignity, and remain constant. The indicators and minimum requirements may need to
be adapted to be meaningful in context. In cases where the standards are not met, any
proposal to reduce the minimum requirements should be considered carefully. Agree any
changes collectively and report the shortfall in actual progress against the minimums
widely. In addition, humanitarian organisations must assess the negative impact on the
population of not meeting a standard and take steps to minimise any harm. Use this
response gap for advocacy and strive to reach the indicators as soon as possible.
The standards apply throughout the programme cycle

The Sphere standards should be used throughout the programme cycle, from
assessment and analysis, through strategy development, planning and programme
design, implementation and monitoring, to evaluation and learning.
Assessment and analysis

The Sphere Minimum Standards provide a basis for needs assessment and
analysis in each sector, with assessment checklists available in each chapter.
At the onset of a crisis, Sphere standards help to identify immediate needs
and prioritise activities that will address these needs. Planning figures and
minimum assistance levels are outlined globally to help formulate minimum
response-wide outcomes. The standards therefore also serve to improve coordi-
nation across organisations and sectors.
Strategy development and programme design

The Core Humanitarian Standard and the Minimum Standards support the
planning of responses to provide the right humanitarian assistance at the right
time to those most in need. The full participation of the affected population
and coordination with national and local authorities is essential to achieve this
across all sectors.
The key actions and indicators provide a framework to identify priorities, determine
planning figures and coordinate across sectors. This helps to ensure that sectoral
responses reinforce each other and support the population’s own capacity to meet
their needs. The key actions and indicators outline the quality of assistance that
should be attained. They also provide a basis for conducting a response analysis
that identifies the best way to meet identified needs and minimise potential
harmful side-effects.
Programme planning usually involves analysis of several response options, such
as in-kind provision of goods, cash-based assistance, direct service provision,
technical assistance or a mix of these. The specific combination of response
options chosen usually evolves over time. The Minimum Standards focus on what
must be done, rather than how the assistance should be delivered.
Cash-based assistance, a form of market-based programming, is increasingly
used to meet humanitarian needs. Considerations for using cash-based assis-
tance have been integrated throughout the Handbook, in all chapters. Cash-based
9
What is Sphere?
assistance can be used to meet multi-sector needs as well as sector-specific

needs. It can also be used to address discriminatory practices that restrict
women’s access to assets and their decision-making around the management of
assets. Multi-purpose grants can be an effective way to provide assistance and
meet standards across sectors. All cash-based assistance should be informed by
a multi-sectoral analysis of needs, dynamics in the context, market functionality
and a feasibility assessment.
Not all sectors are well adapted to market-based programming. This is the case
particularly for providers of direct services or technical assistance. Health and
nutrition providers may choose to support access to existing health service
providers and local public health interventions that do not operate as markets.
To determine the way in which assistance can best be delivered, consultations
with the population, analysis of the markets, knowledge of the ways services are
provided, and an understanding of the supply chain and logistics capacities will
be needed. This response analysis should be reviewed over time as the situation
changes ⊕ see Appendix: Delivering assistance through markets.
Implementation
If the Sphere standards cannot be met for all or some groups from the affected
population, investigate why and explain the gaps, as well as what needs to change.
Assess the negative implications, including protection and public health risks.
Document these issues and work actively with other sectors and the affected
population to identify appropriate ways to minimise potential harm.
Monitoring, evaluation, accountability and learning

Monitoring, evaluation, accountability and learning (MEAL) supports timely and
evidence-based management decisions. It allows humanitarian programmes to
adjust to changing contexts. All of the Minimum Standards have indicators that
can be monitored to determine whether they are being achieved, whether they are
being achieved equitably for all segments of a population, or how much more needs
to be done. Evaluation supports learning to improve policy and future practice,
and promotes accountability. MEAL systems also contribute to broader learning
efforts related to effective humanitarian action.
Understanding vulnerabilities and capacities

Throughout the Handbook, the term “people” has been used in a broad sense,
to reflect Sphere’s belief that all individuals have a right to a life with dignity and
therefore a right to assistance. “People” should be read as including women, men,
boys and girls, regardless of their age, disability, nationality, race, ethnicity, health
status, political affiliation, sexual orientation, gender identity or any other charac-
teristic that they may use to define themselves.
Not all people have equal control of power and resources. Individuals and groups
within a population have different capacities, needs and vulnerabilities, which
10
What is Sphere? – Understanding vulnerabilities and capacities
Assess current situation and trends over time
––Who is affected? ––Protection threats ––Stakeholders and ––Available goods

––Needs and and risks power relationships and services
vulnerabilities ––Security situation ––Capacity and intent ––Market systems
––Coping strategies and rule of law of responders and supply chains
and capacities ––Access to assistance ––Response plans ––Capacity of
––Displaced? Mobile? ––Access to people of authorities and infrastructure
in need? other actors ––Service providers
––What are affected
people’s priorities? ––Seasonal variations ––Role of host (financial and others)
in hazards population ––Logistics capacities,
constraints
Analyse and prioritise
What problems must be addressed? For which groups of people? In what geographic area?
Over what timeframe? Against which standards?
Review options and decide how the response will be delivered
Consider available options From these, select response options

in your context: based on your assessment of:
––Direct service delivery ––Urgency and ––Efficiency, cost-
––Commodity distribution timeliness effectiveness
––Technical assistance ––Feasibility ––Resilience
––Market-based programming ––Capacities ––National ownership
––Cash-based assistance ––Dignity ––Government policy
––Protection
threats, risks
Design a programme built on quality and accountability
Essential lenses Communication Monitoring context, Transition and exit

and accountability process, progress strategies
and results
––Disaggregate ––Feedback and ––Selection of ––Local engagement
data by sex, age complaints indicators and ownership
and disability mechanisms ––Appropriate data ––National systems
––Vulnerabilities ––Coordination disaggregation and ownership
and protection ––Systematic ––Partnerships
––Sustainability community
or transition engagement
Understanding context to apply the standards (Figure 1)
11
What is Sphere?
change over time. Individual factors such as age, sex, disability and legal or health
status can limit access to assistance. These and other factors may also be the
basis of intentional discrimination. Systematic dialogue with women, men, girls
and boys of all ages and backgrounds – both separately and in mixed groups – is
fundamental to good programming. To be young or old, a woman or girl, a person
with a disability or of a minority ethnicity does not in itself make an individual
universally vulnerable. Rather, it is the interplay of factors in a given context that
can strengthen capacities, build resilience or undermine access to assistance for
any individual or group.
In many contexts, entire communities and groups may also be vulnerable because
they live in remote, insecure or inaccessible areas, or because they are geograph-
ically dispersed with limited access to assistance and protection. Groups may be
under-served and discriminated against because of nationality, ethnicity, language,
or religious or political affiliation, which requires special attention to reflect the
principle of impartiality.
When diverse groups are involved in programme design, humanitarian responses
are more comprehensive, inclusive and can have more sustainable results. Inclusion
of, and participation by, the affected population is fundamental to life with dignity.
Data disaggregation
In many situations, population-level data is difficult to find or determine. However,
disaggregated data will show the distinct needs and impact of actions on different
groups. Disaggregated data can help to identify those people most at risk, indicate
whether they are able to access and use humanitarian assistance, and where more
needs to be done to reach them. Disaggregate data to the extent possible and with
categories appropriate to the context to understand differences based on sex or
gender, age, disability, geography, ethnicity, religion, caste or any other factors
that may limit access to impartial assistance.
For general data on age, use the same cohorts as in national data-collection
systems. If there are no national age cohorts, use the table below. More refined
disaggregation may be needed to target specific groups such as infants, children,
youth, women or older people.
Children
Children comprise a significant proportion of any crisis-affected population but are
often less visible. Children’s capacities and needs vary according to their biological
age and stage of development. Special measures must be taken to ensure they are
protected from harm and have equitable access to basic services.
During crises, children face specific life-threatening risks, including malnutrition,
separation from their families, trafficking, recruitment into armed groups, and
physical or sexual violence and abuse, all of which require immediate action.
Protection risks are often compounded by many factors. For example, adoles-
cent and young boys are more likely to be recruited as soldiers by armed forces
12
Sex Disability Age

status 0–5 6–12 13–17 18–29 30–39 40–49 50–59 60–69 70–79 80+
Without
disabilities
Female
With
disabilities
Without
disabilities
Male
With
disabilities
and groups or to participate in the worst forms of child labour. Adolescent girls
are more likely to be recruited as sex slaves or trafficked. Children with disabili-
ties are more likely to be abandoned or neglected. Girls with disabilities require
particular attention because they face greater risk of sexual violence, sexual
exploitation and malnutrition.
Actively seek the views of girls and boys of all ages and backgrounds, so they can
influence how assistance is delivered, monitored and evaluated. The Convention on
the Rights of the Child states that “child” means every person under the age of 18.
Analyse how the affected population defines children, to ensure that no child or
young person is excluded from assistance.
Older people
Older people are a fast-growing proportion of the population in most countries, but
often neglected in humanitarian responses.
In many cultures, being considered old is linked to circumstances (such as being a
grandparent) or physical signs (such as white hair), rather than age. While many
sources define old age as 60 years and older, 50 years may be more appropriate in
contexts where humanitarian crises occur.
Older people bring knowledge and experience of coping strategies and act as
caregivers, resource managers, coordinators and income generators. Older people
often embody traditions and history and act as cultural reference points. Isolation,
physical weakness, disruption of family and community support structures, chronic
illness, functional difficulties and declining mental capacities can all increase the
vulnerability of older people in humanitarian contexts.
Ensure that older people are consulted and involved at each stage of humanitar-
ian response. Consider age-appropriate and accessible services, environments
and information, and use age-disaggregated data for programme monitoring and
management.
Gender
“Gender” refers to the socially constructed differences between women and men
throughout their life cycle. This may change over time and within and across cultures
13
What is Sphere?
and context. Gender often determines the different roles, responsibilities, power and
access to resources of women, girls, boys and men. Understanding these differences
and how they have changed during the crisis is critical to effective humanitarian
programming and the fulfilment of human rights. Crises can be an opportunity to
address gender inequalities and empower women, girls, boys and men.
Gender is not the same as sex, which refers to the biological attributes of a person.
“Gender” does not mean “women only”. While women and girls most often face
constraints within gender roles, men and boys are also influenced by strict expec-
tations of masculinity. Gender equality programming requires their inclusion
for the development of more equitable relationships and equal participation of
women, girls, men and boys.
Gender-based violence
“Gender-based violence” describes violence based on gender differences
between males and females. It underscores how inequality between males and
females is the foundation of most forms of violence perpetrated against women
and girls across the world. Crises can intensify many forms of gender-based
violence, including intimate partner violence, child marriage, sexual violence and
trafficking.
Organisations are responsible for taking all necessary steps to prevent the sexual
exploitation and abuse of people affected by crises, including in their own activities.
When allegations of misconduct are found to be true, it is important that the
competent authorities hold the perpetrator to account and that cases are dealt
with in a transparent way.
Persons with disabilities

About 15 per cent of the world’s population lives with some form of disability.
Persons with disabilities include those who have long-term physical, mental,
intellectual or sensory impairments which, in interaction with various barriers,
may hinder their full and effective participation in society on an equal basis
with others.
In humanitarian contexts, persons with disabilities are more likely to face
barriers and obstacles to the physical environment, transportation, informa-
tion and communications, and humanitarian facilities or services. Response
and preparedness programming should consider the capacities and needs of
all persons with disabilities and make deliberate efforts to remove physical,
communication and attitudinal barriers to their access and participation. Risks
to women and girls with disabilities can be compounded by gender inequality
and discrimination.
⊕ See References: Washington Group Questions for disaggregation of data by disability
status, and the ⊕ Humanitarian inclusion standards for older people and people with
disabilities, for more information.
14
People living with and affected by HIV

Knowing the HIV prevalence in a specific context is important in order to under-
stand vulnerabilities and risks and to inform an effective response. Displacement
may lead to increased HIV vulnerabilities, and crises are likely to cause disruption
in prevention, testing, care, treatment and support services. Specific measures
are often needed to protect against violence and discrimination among high-risk
populations. This can be compounded by gender inequality and discrimination
based on disability status, gender identity and sexual orientation. In turn, this may
discourage people living with HIV to seek services in a crisis, if any are available.
Violence, discrimination and negative coping strategies such as transactional sex
increase vulnerability to HIV transmission, especially for women, girls and LGBTQI
communities. Those at the highest risk include men who have sex with men, people
who inject drugs, sex workers, transgender people, persons with disabilities, and
people in prisons and other closed settings ⊕ see Essential healthcare – sexual and
reproductive health standard 2.3.3: HIV.
Factors such as a reduction in mobility over time and greater access to services
for crisis-affected populations can decrease the risk of HIV. Dispel any possible
misconceptions about the presence of people living with HIV and an increased
HIV prevalence to avoid discriminatory practices. People living with HIV are
entitled to live their lives in dignity, free from discrimination, and should enjoy
non-discriminatory access to services.
LGBTQI people
People who identify as lesbian, gay, bisexual, transgender, queer or intersex
(LGBTQI) are often at heightened risk of discrimination, stigma, and sexual and
physical violence. They may face barriers to accessing healthcare, housing, educa-
tion, employment, information and humanitarian facilities. For example, LGBTQI
people often face discrimination in assistance programmes that are based on
“conventional” family units, such as for emergency accommodation or food
distribution. Such barriers affect their health and survival and may have long-
term consequences on integration. Include specific, safe and inclusive protection
responses in preparedness and planning. Ensure meaningful consultation with
LGBTQI individuals and organisations at each stage of humanitarian response.
Mental health and psychosocial support
People react differently to the stress of a humanitarian crisis. Some are more likely
to be overwhelmed by distress, especially if they have been forcibly displaced,
separated from family members, survived violence or experienced previous mental
health conditions. Providing basic services and security in a socially and culturally
appropriate way is essential to both prevent distress among affected populations
and address discrimination.
Strengthening community psychosocial support and self-help creates a protec-
tive environment, allowing those affected to help each other towards social and
emotional recovery. Focused individual, family or group interventions – including
15
What is Sphere?
clinical interventions – are important, but do not necessarily have to be provided

by mental health professionals. They can also be provided by trained and super-
vised lay people ⊕ see Essential healthcare standard 2.5: Mental healthcare.
Affected populations often express a spiritual or religious identity and may associate
themselves with a faith community. This is often an essential part of their coping
strategy and influences an appropriate response across a wide range of sectors.
There is growing evidence that affected populations benefit when humanitarians
take account of their faith identity. Existing faith communities have great potential
to contribute to any humanitarian response. A people-centred approach requires
humanitarian workers to be aware of the faith identity of affected populations.
There is a growing body of tools to help achieve this.
Understanding the operational setting

Humanitarian response takes place in vastly different contexts, ranging from urban
to rural, and conflict to rapid-onset disaster, and often a combination of these over
time. The effectiveness of the response in meeting the needs of the affected popula-
tion will depend on geographic, security, social, economic, political and environmental
factors. While the Minimum Standards have been developed to focus on immediate
life-saving assistance, they are applicable in humanitarian responses that last a few
days, weeks, months or even years. The humanitarian response should change and
adapt over time and avoid creating aid dependency. A continuous analysis of the
context and situation will signal when programmes should adapt to a changing envi-
ronment, such as new security issues or seasonal constraints such as flooding.
An ongoing evaluation of how the response affects local dynamics such as
procurement of goods and services or hiring of transport is essential to make sure
humanitarian action does not fuel conflict dynamics ⊕ see Protection Principle 2.
When crises become protracted, underlying systemic weaknesses may intensify
needs and vulnerabilities, requiring additional protection and resilience-building
efforts. Some of these will be better addressed through or in cooperation with
development actors.
Coordination mechanisms such as the cluster system are required to establish
a clear division of labour and responsibility and to identify gaps in coverage and
quality. It is important to prevent the duplication of efforts and the waste of
resources. The sharing of information and knowledge between stakeholders,
along with joint planning and integrated activities, can also ensure that organi-
sations manage risk better and improve the outcomes of a response.
Supporting national and local actors

Recognising the primary role and responsibility of the host state, the Handbook
guides all those involved in humanitarian response and the role that humanitarian
organisations can play in supporting this responsibility. In a conflict, the willing-
ness of state or non-state actors to facilitate access to the population will have a
determining effect.
16
What is Sphere? – Understanding the operational setting
The state’s role in leading or coordinating a response will be shaped by many

factors, including:
•• the existence of a government body specifically charged with the coordi-

nation or implementation of humanitarian response (often referred to as a
National Disaster Management Authority or Organisation);
•• the role and strength of line ministries to set standards such as nutrition
standards and standards for essential drugs and medical staff; and
•• the lack of functioning state institutions, such as in contested areas. In such
extraordinary cases, humanitarian actors may need to set up their own
coordination mechanisms.
Protracted crises
When it is evident that a humanitarian response will last more than several
months or years, consider different means of meeting needs and supporting life
with dignity. Explore opportunities to work with existing service providers, local
authorities, local communities, social protection networks or development actors
to help meet needs. Assessments need to consider the context and the protection
concerns, and how the rights of the affected population will be impacted. Involve
individuals of both sexes and all ages, disabilities and backgrounds, including
self-defined communities, in the analysis, assessment, decision-making and
monitoring and evaluation. Pursue long-term and permanent solutions as early as
possible. When humanitarian actors have the opportunity to establish long-term
solutions, those should take precedence over temporary measures.
Recognise that affected people are often the first to respond to their own needs
and protect themselves. National and local authorities, civil society organisations,
faith-based organisations and others provide critical assistance. Be aware of
these pre-existing assistance networks and identify ways to support rather than
undermine or duplicate them.
Urban settings
As more and more of the world’s population moves to towns and cities, humani-
tarians must be prepared to respond in urban contexts. Urban areas typically differ
from other contexts in terms of:
•• Density: a higher density of people, houses, infrastructure, laws and cultures

in a relatively small area;
•• Diversity: social, ethnic, political, linguistic, religious and economically
diverse groups live in close proximity; and
•• Dynamics: urban environments are fluid and changing, with high mobility
and rapidly shifting power relationships.
The municipality will often be the key government authority, with links to other
government actors and departments, such as line ministries. Access to basic
services, food security and livelihoods should be carefully assessed, including
any discrimination. People in cities and towns use cash to pay rent, buy food and
17
What is Sphere?
access healthcare. The Minimum Standards for life with dignity apply, regardless
of how the assistance is provided.
The Sphere Minimum Standards can be used to support multiple entry points for
providing assistance in urban areas, including through settlement, neighbourhood
or area-based approaches. Established groups with shared interests, such as
schools, clubs, women’s groups and taxi drivers, can provide useful entry points.
Working with local actors (such as the private sector, local government, neigh-
bourhood leaders and community groups) can be vital in restarting, supporting
and strengthening existing services instead of replacing them. Be mindful of how
humanitarian assistance may support municipal investment planning, creating
value during the crisis and in the longer term.
As in any setting, a context analysis in urban environments should look at
the existing resources and opportunities, such as commerce, cash, techno
logy, public spaces, people with specialised skill sets, and social and cultural
diversity, alongside risks and protection aspects. The analysis should inform
response options and the final choice of delivery mode, such as deciding to
provide in-kind or cash-based assistance (and the best way for doing so).
The cash-based economy of towns and cities provides opportunities for part-
nerships with actors in markets and technology, which may facilitate the use of
cash-based assistance.
Communal settlements
Planned communal settlements and camps, as well as collective centres and
spontaneous settlements, are home to millions of people who have been forcibly
displaced. The Sphere standards can be used to ensure the quality of assistance
in community settings. They can also help identify priorities for multi-sectoral
programmes to address public health concerns, and for access to basic services in
spontaneous settlements.
In communal settlements, dedicated camp management capacity can contribute
to greater accountability and coordinated service delivery. However, communal
settlements also pose specific protection risks. For example, when the right to
freedom of movement to leave the settlement is denied, people may not be able
to access markets or pursue livelihoods. Special attention should also be paid to
host communities, because real or perceived differences in treatment may lead
to escalating tensions or conflict. In such cases, advocating for an alternative to
camp-like settings and addressing host community needs too can help to ensure
that affected populations are able to live with dignity.
Settings with domestic or international military forces

When humanitarian organisations respond in the same area as domestic
or international military forces, it is important to be aware of each other’s
mandates, modus operandi, capacities and limits. In disaster and conflict
settings, humanitarian organisations may find themselves working closely
18
What is Sphere? – Understanding the operational setting
with a range of militaries, including host government forces, non-state armed

groups and international peacekeepers. Humanitarian actors should note that
host governments are obliged to provide assistance and protection to people
affected by crisis in their territory. Domestic military forces are often mandated
to do this.
Humanitarian principles must guide all humanitarian–military dialogue and coor-
dination at all levels and stages of interaction. Information sharing, planning and
task division are three essential elements of effective civil–military coordination.
While information sharing between humanitarian and military actors can occur,
it must depend on the context of operational activities. Humanitarian agencies
must not share information that gives one party to a conflict a tactical advantage
or endangers civilians.
At times, humanitarian organisations may need to use the unique capabilities of
militaries to support humanitarian operations. Military support to humanitarian
organisations should be limited to infrastructure support and indirect assistance;
direct assistance is a last resort.
Cooperation with militaries has an actual or perceived impact on a humanitar-
ian organisation’s neutrality and operational independence, so must be carefully
considered in advance. Internationally agreed guidance documents should inform
any humanitarian–military coordination arrangements ⊕ see Core Humanitarian
Standard Commitment 6 and References.
Environmental impact in humanitarian response

The environment in which people live and work is essential for their health,
well-being and recovery from crisis. Understanding how affected people are
dependent on the environment for their own recovery can also inform programme
design and lead to more sustainable responses to cope with future shocks and
reduce future risk.
Humanitarian operations affect the environment both directly and indirectly.
Effective humanitarian response should therefore carefully assess environmental
risk alongside wider assessments and situational analysis. Programmes should
minimise their environmental impact and consider how procurement, transport,
choice of materials, or land and natural resource use may protect or degrade
the environment further ⊕ see Shelter and settlement standard 7: Environmental
sustainability.
Countries and regions facing poverty as well as fragile institutional capacity and
ecology are at higher risk of natural disasters and instability, creating a vicious
circle of social and environmental degradation. This has an impact on health,
education, livelihoods and other dimensions of security, dignity and well-being.
Environmental sustainability is an important component of a good quality human-
itarian response ⊕ see Core Humanitarian Standard Commitments 3, 9 and Shelter
and settlement standard 7: Environmental sustainability.
19
WHAT IS SPHERE?
Appendix
Delivering assistance through markets
This appendix complements The Sphere Handbook introduction, providing
further information and guidance on using markets to attain the Minimum
Standards and help people meet their needs in the aftermath of a crisis. It builds
on the foundation chapters and is referenced in the technical chapters. As such, it is
an integral component of The Sphere Handbook. To respond effectively, humani-
tarian actors should understand what the needs are as well as how to practically
meet them. Part of this analysis is understanding how markets are functioning
and what goods and services are available at the local, national, regional and
international level. This understanding also allows humanitarian programmes to
support – or at least not disrupt – markets during the response.
Market analysis as part of response analysis

Once needs and capacities have been assessed to identify priorities, the different
ways to respond and meet those needs should be analysed. Response analysis
should ensure that operational, programmatic and contextual risks and oppor-
tunities are systematically considered when determining how assistance will be
provided. This is sometimes called the “choice of modality”.
Identifying the best way for assistance to meet needs requires:
•• disaggregated information on priorities and how people want to access

assistance, across sectors and over time; and
•• an understanding of economic vulnerabilities, both pre-existing and those
created by the crisis.
As part of response analysis, market analysis helps to identify what may be the
most effective way to meet priority needs: in-kind assistance, service provision,
cash-based assistance or a mix of these in context. Market analysis will help iden-
tify any constraints on markets, including supply and demand issues, or policies,
norms, rules or infrastructure that limit market functioning.
Whichever response option is chosen, it should be market-sensitive and strive to
protect livelihoods, local jobs and businesses. Sphere is based on a fundamental
respect for people affected by crisis and on supporting their choices for their own
recovery. By considering how people interact with local markets to get goods,
services and income, market analysis supports a people-centred approach.
Programming and markets

Assistance can be delivered through markets in many ways at the local,
national or regional level. Market-based programming can be used directly to
20
Appendix – Delivering assistance through markets
deliver assistance, or markets can be supported to better serve the affected

population.
•• Local and regional procurement of commodities and non-food items

supports the supply side of markets.
•• Cash-based assistance, helping people to buy locally available goods or
services, supports the demand side of markets.
•• Support to infrastructure, such as improving road access to markets, or
reforms such as laws to prevent price fixing, support the market so it can
better serve the affected population.
Sex, ethnicity or disability often directly influence physical, financial and social
access to markets. How do men, women, youth and older people access markets
differently? Are traders from a specific ethnicity able to access credit facilities?
These and other factors influence the degree to which individuals can actively
participate in markets.
Ethical and environmental considerations should be weighed when developing
market-based programmes. Ensure that markets that over-exploit natural
resources, ecosystems and the environment are not developed in a way that puts
people at further risk.
Goods, services and markets: When responding to priority humanitarian needs,
consider both goods and services. Most Sphere standards involve providing some
kind of commodity or access to goods. Social sectors such as health and education,
however, are characterised by providing or improving access to services, and deliv-
ering through markets may not be an option. When working with third-party service
providers or sub-contractors, take steps to closely monitor the quality of services
and products with them ⊕ see Health systems standard 1.4: Health financing.
In some cases, market-based programmes that indirectly support access to
services are appropriate. Cash-based assistance can support transport to
healthcare facilities or access to education (buying uniforms and materials).
Tracking household expenditures provides clear data on the cost of accessing
services, including those that should be free. Household expenditure monitoring
should always be supported by outcome monitoring of cash assistance.
Service-based sectors can also consider market-based programming for goods
such as insecticide-treated bednets, supplementary feeding supplies and phar-
maceuticals if they meet quality criteria ⊕ see Health systems standard 1.3: Essential
medicines and medical devices.
In most contexts, a combination of market-based interventions will be needed.
Market-based programmes will likely need to be supported by other activities
such as those providing technical assistance. This combination will also evolve
over the course of the programme and may shift from in-kind to cash or vouchers
or vice versa. Along with programme monitoring, market monitoring is important
to confirm or adjust the form of assistance.
21
WHAT IS SPHERE?
Collaboration between supply chain, logistics and programme functions is needed

at all times. For further guidance on tools that support this choice and analysis
⊕ see References.
Checklists
Checklist for cash-based assistance
This section presents a list of considerations for delivering assistance through
markets. It follows the programme management cycle and includes other impor-
tant elements to consider when adopting this approach to meet the Minimum
Standards. Each context will be different, and the options for delivery mechanisms
will vary based on infrastructure, data protection, cost-effectiveness and financial
inclusion.
Programme design
•• Base targeting criteria on programme objectives and include
cash-based-assistance-specific considerations.
•• Carefully consider who within the household should receive cash-based
assistance, informed by a clear risk assessment and weighing any protection
concerns.
•• Identify safe, accessible and effective mechanisms to deliver assistance
based on the context, objectives and size of the programme as well as on
recipients’ financial literacy and preferences.
•• Calculate the transfer amount based on the needs to be covered and the cost
of meeting these needs.
•• Set the transfer frequency and duration based on needs, seasonality, the
financial service provider’s capacity and protection risks.
•• Where possible and feasible, adopt a multi-sector perspective.
•• Define key issues and related indicators to monitor process, activity, output
and outcome levels.
Implementation
•• Include context-specific considerations and any other relevant dimen-
sions in financial service provider tenders and establish clear criteria
for selection.
•• Consider using existing familiar delivery mechanisms already in place for
social protection.
•• Set up recipient registration and identification systems that are appropriate
to the delivery mechanism and for the protection of personal data.
•• Ensure that registration and identification cover data required by the
financial service provider.
•• Apply and document data protection measures.
•• Set up mechanisms for digital data in collaboration with different organ
isations to the extent possible (“inter-operable systems”).
22
•• Clearly define the procedures, roles and responsibilities for the cash delivery
process, as well as risk management mechanisms.
•• Ensure that the process delivering cash-based assistance is accessible and
effective.
•• Make sure all affected groups can access the chosen delivery mechanism
throughout the project’s lifespan.
•• Ensure recipients have information on programme objectives and the
duration of cash-based assistance, so they can make informed spending
decisions.
•• Ensure financial service providers are accountable to recipients through
contractual management and monitoring ⊕ see Core Humanitarian Standard
Commitments 4 and 5.
Monitoring, evaluation and learning

•• Monitor cash-based-assistance-related processes, activities, outputs and
risks, including through post-distribution monitoring.
•• Monitor whether the cash or vouchers were received by the right person,
safely, on time and in the correct amount.
•• Monitor markets and their supply chains consistently, beyond price
monitoring.
•• Monitor household expenditure and triangulate with market monitoring data
to assess whether needs can indeed be met through cash-based assistance
and negative coping strategies reduced.
•• Monitor potential risks of cash-based assistance, including protection risks
and any negative impact on natural resources.
•• Evaluate outcomes related to cash-based assistance.
•• Regularly evaluate whether the choice of cash-based assistance is effective
in meeting changing needs, adapt the programme accordingly and support
continuous learning for future programmes.
Checklist for supply chain management and logistics

This section presents a list of considerations for supply-chain management
and logistics. It follows the programme management cycle and includes other
important elements to consider.
Supply chain management (SCM) starts with the choice of commodity or service.
It includes identifying the source of what is needed, procurement, quality manage-
ment, risk management (including insurance), packaging, shipping, transportation,
warehousing, inventory management, delivery and distribution. SCM involves
many different partners, and it is important to coordinate activities ⊕ see Core
Humanitarian Standard Commitment 6.
Specific SCM expertise is required. Particular types of relevant expertise include
contract management, transportation and warehouse management, inventory
management, pipeline analysis and information management, shipment tracking
23
WHAT IS SPHERE?
and import management. Management and monitoring practices should ensure

that commodities are safeguarded to distribution points. However, humanitarian
organisations are also responsible for ensuring that products and services (including
cash-based assistance services) reach the people who need assistance.
Local and regional purchasing stimulates local markets, which may give farmers
and manufacturers an incentive to produce more and may in turn boost the local
economy. However, when supplies are already relatively limited, local or regional
purchasing could cause problems in other markets or disrupt existing commercial
networks. Conversely, importing can crowd out local or regional producers and
also disrupt existing commercial networks.
Programme design
•• Assess the local availability of needed goods and services before sourcing
them from outside the area.
•• Consider working with reputable local or regional transporters who have
valuable knowledge of local regulations, procedures and facilities and can
help to ensure compliance with the laws of the host country and to expedite
deliveries.
•• In a conflict environment, apply a particularly rigorous vetting process to
service providers.
•• Carefully ensure that sourcing locally does not cause or exacerbate hostilities.
•• Consider whether any use of natural resources is sustainable and whether
use may lead to further conflict over resources.
•• Establish a transparent, fair and open procedure for awarding contracts,
considering local, national and international options.
•• If several organisations are involved, coordinate local sourcing to the extent
possible.
Implementation
•• Build good relationships with suppliers, local traders and service providers.
•• Enforce the appropriate quality of goods and services through contracts as
well as ethical and environmentally sustainable practices.
•• Train and supervise staff at all levels of the supply chain to maintain product
quality and adhere to, safety procedures (for recipients and staff) as well as
ethical and environmentally sustainable practices.
•• Include staff of partner organisations and service providers in training and
conduct training in the local language.
•• Set up accountability procedures, including supply, transport and storage
planning, inventory management, reporting and financial systems.
•• Avoid using food to pay for logistics operations such as unloading at
warehouses. Such costs should be included in the core budget.
•• Separate warehouses for food and non-food items are recommended.
When selecting a warehouse, establish that it has not been used to store
hazardous goods and that there is no danger of contamination. Factors to
24
consider include: security, capacity, ease of access, structural solidity and

absence of any threat of flooding.
•• Assess and manage risks to the security of transport routes and
warehouses.
•• In conflict situations, establish control systems and supervise all stages
of the supply chain to minimise the risk of looting or requisitioning by
warring parties.
•• Analyse and address broader political and security implications, such as
the possibility of diverted stocks fuelling an armed conflict ⊕ see Protection
Principle 2.
•• Minimise and report product losses at all levels of the supply chain.
•• Have damaged or unsuitable commodities inspected by qualified inspectors
(such as food safety experts and public health laboratories) and certified
for disposal.
•• Dispose of damaged commodities quickly, before they become a health
or security hazard. Methods of commodity disposal include sale (for
example or food for animal feed) and burial or incineration that is author-
ised and should be witnessed by relevant authorities. In all cases, unfit
commodities must not re-enter the supply chain, harm the environment
or contaminate water sources ⊕ see WASH Solid waste management
standards 5.1 to 5.3.
•• Day-to-day management needs include prompt and transparent reporting of
any delays or deviations in the supply chain. Make sufficient documentation
and forms available in the local language at all locations where goods are
received, stored and/or dispatched. Doing so maintains a documented audit
trail of transactions.
Monitoring, evaluation and learning

•• Monitor and manage commodity pipelines to avoid diversion of and interrup-
tion to distributions, as well as to avoid market distortion.
•• Inform stakeholders regularly about the performance of supply chain efforts.
•• Share relevant information on stock levels, expected arrivals and distribu-
tions among supply chain stakeholders. Use the tracking of stock levels to
highlight anticipated shortfalls and problems in time. Information sharing
among partners may facilitate loans that prevent pipeline breaks. If there
are insufficient resources, commodities will need to be prioritised. Consult
stakeholders when considering solutions.
•• Ensure that accountability and communication mechanisms reflect the
specificities of delivery processes.
•• Ensure commodity tracking and information management systems are in
place from the beginning of the intervention.
•• Evaluate regularly if the assistance is effective in meeting changing needs,
adapt the programme accordingly and support continuous learning for
future programmes.
25
WHAT IS SPHERE?
References and further reading

Understanding vulnerabilities and capacities
Humanitarian Inclusion Standards for Older People and People with Disabilities.
Age and Disability Consortium as part of the ADCAP programme. HelpAge, 2018.
www.helpage.org
Faith-based programming
A faith-sensitive approach in humanitarian response: Guidance on mental health
and psychosocial programming. The Lutheran World Federation and Islamic Relief
Worldwide, 2018. https://interagencystandingcommittee.org
Market analysis and market-based programming

Minimum Economic Recovery Standards (MERS): Core Standard 2 and Assessment
and Analysis Standards. The Small Enterprise Education and Promotion Network
(SEEP), 2017. https://seepnetwork.org
Minimum Standard for Market Analysis (MISMA). The Cash Learning Partnership
(CaLP), 2017. www.cashlearning.org
Cash-based assistance
CBA Programme Quality Toolbox. CaLP. http://pqtoolbox.cashlearning.org
Supply chain management and logistics

Cargo Tracking: Relief Item Tracking Application (RITA). Logistics Cluster.
www.logcluster.org
HumanitarianResponse.info: Logistics references page. UNOCHA.
https://www.humanitarianresponse.info
Logistics Operational Guide (LOG). Logistics Cluster. http://dlca.logcluster.org
Oxfam Market Systems and Scenarios for CTP – RAG Model 2013. Logistics Cluster.
www.logcluster.org
Toolkit for Logistics in C&V. Logistics Cluster. www.logcluster.org
Further reading
For further reading suggestions please go to
www.spherestandards.org/handbook/online-resources
26
The
Humanitarian
Charter
THE HUMANITARIAN CHARTER
The Humanitarian Charter

The Humanitarian Charter provides the ethical and legal backdrop to the Protection
Principles, the Core Humanitarian Standard and the Minimum Standards that
follow in the Handbook. It is in part a statement of established legal rights and
obligations, in part a statement of shared belief.
In terms of legal rights and obligations, the Humanitarian Charter summarises
the core legal principles that have most bearing on the welfare of those affected
by disaster or conflict. With regard to shared belief, it attempts to capture a
consensus among humanitarian agencies on the principles which should govern
the response to disaster or conflict, including the roles and responsibilities of the
various actors involved.
The Humanitarian Charter forms the basis of a commitment by humanitarian
agencies that endorse Sphere and an invitation to all those who engage in human-
itarian action to adopt the same principles.
Our beliefs
1. The Humanitarian Charter expresses our shared conviction as humanitarian
agencies that all people affected by disaster or conflict have a right to receive
protection and assistance to ensure the basic conditions for life with dignity.
We believe that the principles described in this Humanitarian Charter are univer-
sal, applying to all those affected by disaster or conflict, wherever they may
be, and to all those who seek to assist them or provide for their security. These
principles are reflected in international law, but derive their force ultimately from
the fundamental moral principle of humanity: that all human beings are born free
and equal in dignity and rights. Based on this principle, we affirm the primacy of
the humanitarian imperative: that action should be taken to prevent or alleviate
human suffering arising out of disaster or conflict, and that nothing should over-
ride this principle.
As local, national and international humanitarian agencies, we commit to promoting
and adhering to the principles in this Charter and to meeting Minimum Standards
in our efforts to assist and protect those affected. We invite all those who engage
in humanitarian activities, including governmental and private sector actors, to
endorse the common principles, rights and duties set out below as a statement of
shared humanitarian belief.
Our role
2. We acknowledge that it is firstly through their own efforts, and through the
support of community and local institutions, that the basic needs of people
affected by disaster or conflict are met. We recognise the primary role and respon-
sibility of the affected state to provide timely assistance to those affected, to
28
The Humanitarian Charter – Common principles, rights and duties
ensure people’s protection and security and to provide support for their recovery.
We believe that a combination of official and voluntary action is crucial to effective
prevention and response, and in this regard National Societies of the Red Cross
and Red Crescent Movement and other civil society actors have an essential role
to play in supporting public authorities. Where national capacity is insufficient,
we affirm the role of the wider international community, including governmental
donors and regional organisations, in assisting states to fulfil their responsibilities.
We recognise and support the special roles played by the mandated agencies of
the United Nations and the International Committee of the Red Cross.
3. As humanitarian agencies, we interpret our role in relation to the needs and
capacities of affected populations and the responsibilities of their governments or
controlling powers. Our role in providing assistance reflects the reality that those
with primary responsibility are not always fully able to perform this role them-
selves, or may be unwilling to do so. As far as possible, consistent with meeting
the humanitarian imperative and other principles set out in this Charter, we will
support the efforts of the relevant authorities to protect and assist those affected.
We call upon all state and non-state actors to respect the impartial, independent
and non-partisan role of humanitarian agencies and to facilitate their work by
removing unnecessary legal and practical barriers, providing for their safety and
allowing them timely and consistent access to affected populations.
Common principles, rights and duties

4. We offer our services as humanitarian agencies on the basis of the principle
of humanity and the humanitarian imperative, recognising the rights of all people
affected by disaster or conflict – women and men, boys and girls. These include
the rights to protection and assistance reflected in the provisions of international
humanitarian law, human rights and refugee law. For the purposes of this Charter,
we summarise these rights as follows:
•• the right to life with dignity;

•• the right to receive humanitarian assistance; and
•• the right to protection and security.
While these rights are not formulated in such terms in international law, they
encapsulate a range of established legal rights and give fuller substance to the
humanitarian imperative.
5. The right to life with dignity is reflected in the provisions of international
law, and specifically the human rights measures concerning the right to life, to
an adequate standard of living and to freedom from torture or cruel, inhuman or
degrading treatment or punishment. The right to life entails the duty to preserve
life where it is threatened. Implicit in this is the duty not to withhold or frustrate the
provision of life-saving assistance. Dignity entails more than physical well-being; it
demands respect for the whole person, including the values and beliefs of individu-
als and affected communities, and respect for their human rights, including liberty,
freedom of conscience and religious observance.
29
6. The right to receive humanitarian assistance is a necessary element of the

right to life with dignity. This encompasses the right to an adequate standard
of living, including adequate food, water, clothing, shelter and the requirements
for good health, which are expressly guaranteed in international law. The Core
Humanitarian Standard and the Minimum Standards reflect these rights and
give practical expression to them, specifically in relation to the provision
of assistance to those affected by disaster or conflict. Where the state or
non-state actors are not providing such assistance themselves, we believe
they must allow others to help do so. Any such assistance must be provided
according to the principle of impartiality, which requires that it be provided
solely on the basis of need and in proportion to need. This reflects the wider
principle of non-discrimination: that no one should be discriminated against
on any grounds of status, including age, gender, race, colour, ethnicity, sexual
orientation, language, religion, disability, health status, political or other
opinion, and national or social origin.
7. The right to protection and security is rooted in the provisions of inter-
national law, in resolutions of the United Nations and other intergovernmental
organisations, and in the sovereign responsibility of states to protect all those
within their jurisdiction. The safety and security are of particular humanitarian
concern, including the protection of refugees and internally displaced persons.
As the law recognises, some people may be particularly vulnerable to abuse and
adverse discrimination due to their status, for example their age, gender or race,
and may require special measures of protection and assistance. To the extent
that a state lacks the capacity to protect people in these circumstances, we
believe it must seek international assistance to do so.
The law relating to the protection of civilians and displaced people demands
particular attention here:
i. During armed conflict as defined in international humanitarian law, specific

legal provision is made for protection and assistance to be given to those
not engaged in the conflict. In particular, the 1949 Geneva Conventions and
the Additional Protocols of 1977 impose obligations on the parties to both
international and non-international armed conflicts. We stress the general
immunity of the civilian population from attack and reprisals, and in particu-
lar the importance of:
•• the principle of distinction between civilians and combatants, and

between civilian objects and military objectives;
•• the principles of proportionality in the use of force and precaution
in attack;
•• the duty to refrain from the use of weapons that are indiscriminate
or that, by their nature, cause superfluous injury or unnecessary
suffering; and
•• the duty to permit impartial relief to be provided.
Much of the avoidable suffering caused to civilians in armed conflicts stems
from a failure to observe these basic principles.
30
The Humanitarian Charter – Our commitment
ii. The right to seek asylum or sanctuary remains vital to the protection
of those facing persecution or violence. Those affected by disaster or
conflict are often forced to flee their homes in search of security and the
means of subsistence. The provisions of the 1951 Convention Relating to
the Status of Refugees (as amended) and other international and regional
treaties provide fundamental safeguards for those unable to secure
protection from the state of their nationality or residence who are forced
to seek safety in another country. Chief among these is the principle of
non-refoulement: the principle that no one shall be sent back to a country
where their life, freedom or physical security would be threatened or
where they are likely to face torture or other cruel, inhuman or degrading
treatment or punishment. The same principle applies by extension to
internally displaced persons, as reflected in international human rights law
and elaborated in the 1998 Guiding Principles on Internal Displacement and
related regional and national law.
Our commitment
8. We offer our services in the belief that the affected population is at the centre
of humanitarian action, and recognise that their active participation is essential to
providing assistance in ways that best meet their needs, including those of vulner-
able and socially excluded people. We will endeavour to support local efforts to
prevent, prepare for and respond to disaster and to the effects of conflict, and to
reinforce the capacities of local actors at all levels.
9. We are aware that attempts to provide humanitarian assistance may sometimes
have unintended adverse effects. In collaboration with affected communities and
authorities, we aim to minimise any negative effects of humanitarian action on the
local community or on the environment. With respect to armed conflict, we recog-
nise that the way in which humanitarian assistance is provided may potentially
render civilians more vulnerable to attack, or may on occasion bring unintended
advantage to one or more of the parties to the conflict. We are committed to
minimising any such adverse effects, in so far as this is consistent with the
principles outlined above.
10. We will act in accordance with the principles of humanitarian action set out
in this Charter and with the specific guidance in the Code of Conduct for the
International Red Cross and Red Crescent Movement and Non-Governmental
Organisations (NGOs) in Disaster Relief (1994).
11. The Core Humanitarian Standard and the Minimum Standards give prac-
tical substance to the common principles in this Charter, based on agencies’
understanding of the basic minimum requirements for life with dignity and their
experience of providing humanitarian assistance. Though the achievement of
the standards depends on a range of factors, many of which may be beyond our
control, we commit ourselves to attempting consistently to achieve them and we
expect to be held to account accordingly. We invite all parties, including affected
and donor governments, international organisations, and private and non-state
31
actors, to adopt the Core Humanitarian Standard and the Minimum Standards as
accepted norms.
12. By adhering to the Core Humanitarian Standard and the Minimum Standards,
we commit to making every effort to ensure that people affected by disasters or
conflict have access to at least the minimum requirements for life with dignity
and security, including adequate water, sanitation, food, nutrition, shelter and
healthcare. To this end, we will continue to advocate that states and other parties
meet their moral and legal obligations towards affected populations. For our part,
we undertake to make our responses more effective, appropriate and accountable
through sound assessment and monitoring of the evolving local context, through
transparency of information and decision-making, and through more effective
coordination and collaboration with other relevant actors at all levels, as detailed
in the Core Humanitarian Standard and the Minimum Standards. In particular,
we commit to working in partnership with affected populations, emphasising
their active participation in the response. We acknowledge that our fundamental
accountability must be to those we seek to assist.
32
Protection
Principles
Humanitarian Charter
principle 1 principle 2 principle 3 principle 4
Enhance people’s Ensure people’s Assist people to Help people to claim

safety, dignity and access to impartial recover from the their rights
rights and avoid assistance, according physical and psycho-
exposing them to to need and without logical effects
further harm discrimination of threatened or actual
violence, coercion or
deliberate deprivation
Appendix Summary of Professional Standards for Protection Work
34
Contents
Protection Principles...................................................................................................................36
Principle 1..................................................................................................................................38
Principle 2..................................................................................................................................40
Principle 3..................................................................................................................................41
Principle 4..................................................................................................................................43
Appendix: Summary of Professional Standards for Protection Work........................45
35
Four Protection Principles apply to all humanitarian action and all humanitarian
actors.
1. Enhance the safety, dignity and rights of people, and avoid exposing them
to harm.
2. Ensure people’s access to assistance according to need and without
discrimination.
3. Assist people to recover from the physical and psychological effects of
threatened or actual violence, coercion or deliberate deprivation.
4. Help people claim their rights.
The Protection Principles support the rights set out in the Humanitarian Charter:
the right to life with dignity, the right to humanitarian assistance and the right to
protection and security. The Principles articulate the role that all humanitarian
actors can play in helping protect people. The roles and responsibilities of human-
itarian actors are, however, secondary to those of the state. The state or other
authorities hold legal responsibility for the welfare of people within their territory
or control and for the safety of civilians in armed conflict. Ultimately, it is these
authorities that have the duty to ensure people’s security and safety through action
or restraint. The role of humanitarian actors may be to encourage and persuade
the authorities to fulfil their responsibilities and, if they fail to do so, assist people
in dealing with the consequences.
This chapter provides guidance on how humanitarian organisations can contribute
to protection by helping people stay safe, access assistance, recover from violence
and claim their rights.
Protection is concerned with the safety, dignity and rights of people affected by
disaster or armed conflict. The Inter-Agency Standing Committee (IASC) defines
protection as:
“… all activities aimed at obtaining full respect for the rights of the individual in
accordance with the letter and the spirit of the relevant bodies of law (i.e. international
human rights law, international humanitarian law, international refugee law).”
In a broad sense, protection encompasses all efforts pursued by humanitarian and
human rights actors to ensure that the rights of affected persons and the obligations of
duty bearers under international law are understood, respected, protected and fulfilled
without discrimination.
Protection is about taking action to keep people safe from violence, coercion and
deliberate deprivation. There is often a priority set of protection concerns affecting
whole communities in any given humanitarian context, where concerted action is
essential if these are to be effectively tackled. For a humanitarian response to be
protection-oriented, it is vital to understand and address the key risks to those
affected, including serious harm arising from the failure to respect international
humanitarian, refugee or human rights law.
36
Protection Principles – Putting the Principles into practice
Putting the Principles into practice

Anyone applying the Sphere Minimum Standards should be guided by the Protection
Principles, even if they do not have a distinct protection mandate or specialised
capacity in protection. This includes understanding the context and taking steps to
prevent, limit or end violations and risks to people’s safety. Providing information
and supporting the ability of people to make informed decisions about their own
situation and recovery is essential.
Specialised protection actors should fulfil these Principles in addition to meeting
specific complementary standards. Specialised protection actors carry out stand-
alone work focusing on specific areas of concern such as:
•• child protection;
•• gender-based violence;
•• housing, land and property rights;
•• mine action;
•• rule of law and justice;
•• legal counselling;
•• human rights advocates and defenders;
•• internally displaced populations; and
•• refugee rights.
⊕ See References and Appendix: Professional Standards for Protection Work, which
cover family tracing, renewal of documents, data protection and other areas.
Protection activities
Protection-related activities can be preventive, responsive, remedial and environ-
ment-building. Upholding the Protection Principles requires a combination of these
activities.
•• Preventive: Preventing threats to safety, dignity or rights from occurring, or

reducing exposure or vulnerability to these threats.
•• Responsive: Stopping ongoing violations or abuse by immediate response to
incidents of violence, coercion and deprivation.
•• Remedial: Providing remedies for ongoing or past abuses by offering
healthcare (including psychosocial support), legal assistance or other
support, to help people restore their dignity.
•• Environment-building: Contributing to a policy, social, cultural, institutional
and legal environment that supports the full respect of the rights of the
affected population. This includes encouraging respect for rights in accord-
ance with international law.
Advocacy, whether public or private, is common to all four activity types. Where
threats to the affected population come from deliberate decisions, actions or poli-
cies, humanitarian or human rights organisations should advocate for changes to
decisions, actions or policies that threaten the rights of the affected population.
This may include influencing or changing the behaviour of a person or organisation
37
that poses a threat, as well as seeking change in discriminatory policies or legal

frameworks. It may also include supporting people’s own efforts to stay safe and
reducing people’s exposure to risk.
Protection Principle 1:
Enhance people’s safety, dignity and rights
and avoid exposing them to further harm
Humanitarian actors take steps to reduce overall risks and vulnerability
of people, including to the potentially negative effects of humanitarian
programmes.
This Principle includes:

•• Understanding protection risks in context;
•• Providing assistance that reduces risks that people may face in meeting their
needs with dignity;
•• Providing assistance in an environment that does not further expose people
to physical hazards, violence or abuse; and
•• Supporting the capacity of people to protect themselves.
Central to this principle is the importance of avoiding negative effects caused by
humanitarian programming ⊕ see Core Humanitarian Standard Commitment 3.
Guidance notes
Context analysis: Understand the context and anticipate the consequences of
humanitarian action that may affect the safety, dignity and rights of the affected
population. Work with partners and groups of affected women, men, boys and girls
to do regular risk analysis as the situation changes over time.
The following list is not exhaustive but can form a basis for such an analysis:
•• What are the protection threats, risks and vulnerabilities across the whole
population? What capacities does the population have to minimise those?
•• Are there groups that face specific risks? Why? Consider, for example,
ethnicity, caste, class, gender, sex, age, disability or sexual orientation.
•• Are there obstacles preventing people from accessing assistance or partic-
ipating in decisions? These may include security, social or physical barriers,
or how information is provided.
•• What are local communities doing to protect themselves? How can human-
itarian organisations support and not undermine these efforts? Are there
risks to people protecting themselves?
•• Are people engaged in negative coping mechanisms such as transactional
sex, early marriage, child labour or risky migration? What can be done to
mitigate the underlying vulnerabilities?
38
PROTECTION PRINCIPLE 1: Enhance people’s safety, dignity and rights
•• Are humanitarian activities having unintended negative consequences,

such as putting people at risk at distribution points or causing division
within the community or with host communities? What can be done to
reduce this risk?
•• Are there punitive laws that pose a protection risk, such as mandatory
testing for HIV, criminalisation of same-sex relationships, or other?
Set up and maintain information exchange and accountability mechanisms with
communities, including those at risk, to identify and address protection issues.
Avoid becoming complicit in violations of people’s rights through activities that
give legitimacy to the policies and practices that cause the problem. Examples
may include activities that enable the forced relocation of populations for political
or military reasons, or indirectly increasing conflict through careless choice of
partners or commercial contractors. This analysis may involve difficult choices
and decisions, but it should be explicitly considered and reviewed as circum-
stances change.
Humanitarian assistance: The way that assistance is provided, and the environ-
ment in which it is provided, can make people more vulnerable to harm, violence
or coercion.
•• Provide assistance in the safest possible environment and actively look

for ways to minimise threats and vulnerabilities. For instance, provide
education and healthcare in locations that all people can safely access
⊕ see INEE Handbook.
•• Take all reasonable steps when providing and managing assistance to
protect people from physical and sexual assault. For example, valuable
commodities or cash-based assistance can be subject to looting, putting
recipients at risk of harm.
•• Help people find safe options for meeting basic needs in a way that reduces
exposure to risks. For example, provide fuel alternatives that reduce the
need to collect firewood in dangerous environments.
•• Design activities that protect girls and boys, and do not create additional
risks, such as child recruitment, abduction or separation from family ⊕ see
CPMS Handbook.
•• Coordinate with government authorities and specialised organisations
on the removal of landmines and unexploded ordnance from areas where
assistance is provided ⊕ see International Mine Action Standards.
•• Consider any unintended impact on the environment that could affect
people’s safety, dignity and rights.
•• Consult with different parts of the community, including at-risk groups and
organisations they trust, to understand the best way to provide assistance.
For example, work with persons with disabilities to determine how to provide
assistance. There should be no additional risks to their well-being or to the
well-being of the people they trust to receive assistance on their behalf.
39
Community protection mechanisms: Understand the means by which people try

to protect themselves, their families and communities. Support community-led
self-help initiatives. Humanitarian interventions should not compromise people’s
capacity to protect themselves and others.
Sensitive information: Ensure that people are not put at risk as a result of the
way that humanitarian actors record and share information. Establish a policy
on collecting and referring sensitive information. It should define the circum-
stances under which information may be referred and respect the principle of
informed consent. Failure to do so may compromise the safety of survivors
and of staff.
Ensure people’s access to impartial assistance,
according to need and without discrimination
Humanitarian actors identify obstacles to accessing assistance and take steps
to ensure it is provided in proportion to need and without discrimination.

•• Challenging any actions that deliberately deprive people of their basic
needs, using humanitarian principles and relevant law ⊕ see Humanitarian
Charter;
•• Ensuring people receive support on the basis of need, and that they are not
discriminated against on any other grounds; and
•• Ensuring access to assistance for all parts of the affected population.
Central to this principle is the idea that communities should have access to
the humanitarian assistance they need ⊕ see Core Humanitarian Standard
Commitment 2.
Guidance notes
Impartiality: Prioritise assistance on the basis of need alone and provide assis-
tance in proportion to need. This is the principle of impartiality affirmed in the Code
of Conduct for the International Red Cross and Red Crescent Movement and NGOs
in Disaster Relief ⊕ see Annex 2 and Humanitarian Charter. Humanitarian organ-
isations should not focus uniquely on a particular group (for example, displaced
people in a campsite or specific minority groups) if this focus is to the detriment of
another group in the affected population that is in need.
Right to receive humanitarian assistance: Advocate for the right of people affected
by crisis to receive humanitarian assistance. Where people are unable to meet
their basic needs and the relevant authorities are unable to provide assistance,
the authorities should not deny access to impartial humanitarian organisations.
40
PROTECTION Principle 3: ASSIST PEOPLE TO RECOVER
Such denial may violate international law, particularly in situations of armed

conflict. People affected by crisis do not need to have a special legal status in order
to receive humanitarian assistance and protection.
Authorities should not deny the existence of humanitarian needs or use bureau-
cratic barriers to restrict movement of humanitarian workers.
Barriers to access: Monitor people’s access to humanitarian assistance to
identify and understand any barriers they may face. Take steps to address these
where possible.
•• Consider barriers that reduce people’s freedom of movement or their physical

access to humanitarian assistance. This includes blockades, landmines and
checkpoints. In armed conflict, parties may establish checkpoints, but these
should not discriminate between categories of affected people or unduly
hinder people’s access to humanitarian assistance.
•• Address barriers that may restrict access by some groups and individuals,
resulting in inequitable assistance. Barriers may lead to discrimination
against women and children, older people, persons with disabilities or
minorities. They may also prevent people accessing assistance on the basis
of ethnic, religious, political, sexual orientation, gender identity, language or
other considerations.
•• Provide information, in accessible formats and languages, about entitlements
and feedback mechanisms. Promote outreach with “hidden” at-risk groups,
such as persons with disabilities, children living on the streets, or those living
in less accessible regions, to facilitate their safe access to assistance.
Assist people to recover from the physical and
psychological effects of threatened or actual violence,
coercion or deliberate deprivation
Humanitarian actors provide immediate and sustained support to those
harmed by violations, including referral to additional services as appropriate.

•• Referring survivors to relevant support services;
•• Taking all reasonable steps to ensure that the affected population is not
subject to further violence, coercion or deprivation; and
•• Supporting people’s own efforts to recover their dignity and rights within
their communities and be safe.
Central to this Principle is the idea that communities and people affected by crisis
receive coordinated, complementary assistance ⊕ see Core Humanitarian Standard
Commitment 6.
41
Guidance notes
Referrals: Be aware of the existing referral systems and help people affected by
violence to safely access appropriate services. Some people may not seek assis-
tance after a violation. Take steps to understand the barriers that stop people from
seeking assistance and adapt the referral system accordingly.
Support survivors of physical or gender-based violence to access services
such as healthcare, police assistance, mental health and psychosocial support,
and other services. These services should be sensitive to the people’s sex, age,
disability, sexual orientation and other relevant factors ⊕ see Guidelines for
Integrating Gender-based Violence Interventions in Humanitarian Action.
Set up and use safe and effective referral mechanisms to child protection services that
support children who are survivors of violence, exploitation, abuse and neglect.
Community action: Support community action and self-help activities that help to
restore people’s sense of agency and improve their protection.
Support family, community and individual response mechanisms of protection,
and mental health and psychosocial support. This can include creating opportuni-
ties where people can discuss their situation, choose particular protection threats
to be addressed, and develop and implement steps for addressing them.
Help local groups such as youth groups, women’s groups or religious groups to
implement non-violent means of self-protection, and support vulnerable people.
Wherever possible, keep families together, including non-traditional families, and
enable people from a particular village or support network to live in the same area.
Support positive communal coping mechanisms such as culturally appropriate
burials, religious ceremonies and practices, and non-harmful cultural and social
practices.
Ongoing violations, monitoring and reporting: Be aware of mechanisms to report
on human rights violations and follow the procedures and policies in place for
safe sharing of sensitive information ⊕ see Protection Principle 1 and Appendix:
Professional Standards for Protection Work.
Ongoing violations must also be considered and addressed with partners and
specialised agencies. The primary responsibility to protect people resides with
the government and other relevant authorities. Work with specialised agencies
to identify those parties who have the legal responsibility or capacity to provide
protection and remind them of their obligations.
Security and law enforcement agencies, police, and military and peacekeeping
forces play an important role in ensuring the physical security of people. When
appropriate and safe to do so, alert police or law enforcement or military actors
to violations of human rights.
During armed conflict, consider monitoring the institutions that provide essential
services and are specifically protected under international humanitarian law, such
42
Protection Principle 4: Help people to claim their rights
as schools and hospitals, and reporting any attacks on them. Make specific efforts
to reduce the risks and threats of abductions or forced recruitment that may
happen in these locations.
Managing sensitive information: Humanitarian organisations should have clear
policies and procedures to guide staff on how to respond if they become aware
of or witness abuses, and on how to make referrals to specialists or specialised
agencies. The confidentiality of the information should be explained in those
policies.
Evidence such as witness statements, population profiles and images that allow
people to be identified may be highly sensitive and can put people at risk. Sensitive
information on specific abuses or violations should be collected by specialised
agencies with the necessary skills, systems, capacity and protocols in place ⊕ see
Appendix: Professional Standards for Protection Work.
Help people to claim their rights
Humanitarian actors help affected communities claim their rights through
information and documentation, and support efforts to strengthen respect
for rights.

•• Supporting people to assert their rights and to access remedies from
government or other sources;
•• Assisting people to secure the documentation they need to demonstrate
their entitlements; and
•• Advocating for full respect of people’s rights and international law,
contributing to a stronger protective environment.
Central to this Principle is that people affected by crisis should know their rights
and entitlements ⊕ see Core Humanitarian Standard Commitment 4.
Guidance notes
Accessible information: Provide education and information that enable people to
understand and advocate for their rights. Inform people of their entitlements,
for example in relation to return and resettlement options. Work with specialised
organisations providing legal aid to inform people of their rights under the laws and
regulations of the country.
Provide information in languages that affected people can understand. Use
multiple formats (such as written, graphic or audio) to make information as widely
accessible as possible. Test message comprehension with different groups,
considering variations in age, gender, education level and mother tongue.
43
Documentation: People generally have rights, regardless of whether they possess

particular documentation. However, without some form of documentation such
as a birth certificate, marriage certificate, death certificate, passport, land title or
education certificate, people may face barriers to accessing their rights or entitlements.
Refer them to agencies that can provide or replace these documents.
Legal documentation recognised by the relevant authorities should not be
confused with documents issued by humanitarian organisations, such as ration
cards or registration documents. Documentation issued by authorities should not
determine who is eligible for assistance from humanitarian organisations.
Access to legal support and justice systems: People are entitled to seek legal and
other redress from the government and relevant authorities for violations
of their rights. This can include compensation for loss or restitution of property.
People are also entitled to expect that the perpetrators of violations will be
brought to justice.
Assist those who choose legal remedies to access justice mechanisms in a safe
manner. Effective referral requires an understanding of which agencies can provide
legal support.
Avoid promoting access to justice in situations where the judicial process might
cause further harm to victims. For instance, healthcare providers and gender-
based violence referral networks should be aware of the national medico-legal
system and the relevant laws on sexual violence. Inform survivors about any
mandatory reporting laws that could limit the confidentiality of the information
patients disclose. This may influence the survivor’s decision to continue care or
reporting, but must be respected ⊕ see Health: Sexual and reproductive health
standard 2.3.2.
During crises, affected communities may be able to use alternative and informal
dispute-resolution mechanisms, such as community-level mediation. Where
these exist, inform people and explain how they can access the services.
Land access and ownership can be major points of contention. Encourage author-
ities and communities to work together to resolve issues relating to access or
ownership of land.
44
Appendix – Summary of Professional Standards for Protection Work
Appendix
Summary of Professional Standards for
Protection Work
In armed conflict or other situations of violence, the protection of civilians
who may be exposed to harm and suffering is critical. An effective protection
response requires professional competence and adherence to commonly agreed
professional Minimum Standards that are applicable to all protection actors.
The Professional Standards for Protection Work were established to create a
shared basis for protection work among humanitarian and human rights actors,
and to maximise the effectiveness of that work for the affected population. They
complement the Protection Principles.
The standards reflect the view that people must be at the centre of action taken on
their behalf. People have a meaningful role to play in analysing, developing and moni-
toring protection responses to the threats and risks they face. Beyond improving
people’s physical security, protection efforts should promote respect of the rights,
dignity and integrity of those at risk or subject to violations and abuse.
The range of activities implemented by humanitarian actors varies greatly, and it
is essential for all actors to integrate protection concerns into their practice in line
with the Protection Principles. The Professional Standards are primarily intended
for protection professionals and organisations implementing dedicated protection
work in armed conflict and other situations of violence.
The professional standards offer organisations a solid basis from which to review and
develop internal policies, guidelines and training materials. They offer a practical refer-
ence for practitioners who design and implement protection strategies at field level.
They can also serve as a source of inspiration. They are a useful reference point to help
other actors and stakeholders understand how specialised protection actors safely
implement activities to enhance the protection of individuals and communities.
These standards do not seek to regulate protection work or restrict diversity, but
rather complement other professional principles and encourage protection actors
to integrate them into their own practices, guidelines and training.
The 2018 Professional Standards are organised as follows:
1. Overarching principles in protection work
2. Managing protection strategies
3. Outlining the protection architecture
4. Building on the legal base of protection
5. Promoting complementarity
6. Managing data and information for protection outcomes
7. Ensuring professional capacities
45
PROTECTION PRINCIPLES
The standards include a view on the implications of information and communi

cation technology (ICT) and the growing body of law on data protection, with
specific guidance on protection information management.
Dialogue and interaction between humanitarian and human rights actors and
United Nations peacekeeping operations and other internationally mandated
military and police forces are often necessary to secure protection outcomes.
The Professional Standards provide guidance on upholding a principled approach
in these interactions.
National, regional and international efforts to tackle “violent extremism”
through counter-terrorism legislation are also addressed in the Professional
Standards, clarifying how this kind of legislation may affect the activities of
protection actors.
Download the Professional Standards for Protection Work from the International
Committee of the Red Cross (ICRC) e-Book store:
https://shop.icrc.org/e-books/icrc-activities-ebook.html.
46

General protection: background and tools
Minimum Agency Standards for Incorporating Protection into Humanitarian Response –
Field Testing Version. Caritas Australia, CARE Australia, Oxfam Australia and World
Vision Australia, 2008. http://sitap.org
Policy on Protection in Humanitarian Action. IASC, 2016. www.interagencystanding-
committee.org
Professional Standards for Protection Work Carried Out by Humanitarian and Human
Rights Actors in Armed Conflict and Other Situations of Violence. ICRC, 2018.
https://shop.icrc.org
Guidelines for Integrating Gender-based Violence Interventions in Humanitarian Action:
Reducing risk, promoting resilience, and aiding recovery. IASC, 2015. gbvguidelines.org
Housing, land and property rights

Principles on Housing and Property Restitution for Refugees and Displaced Persons.
OHCHR, 2005. www.unhcr.org
Internally displaced persons

Handbook for the Protection of Internally Displaced Persons. Global Protection
Cluster, 2010. www.globalprotectioncluster.org

IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings.
IASC, 2007. https://interagencystandingcommittee.org
Mine action
International Mine Action Standards. www.mineactionstandards.org
Older persons and persons with disabilities

Humanitarian Inclusion Standards for Older People and People with Disabilities. Age and
Disability Consortium as part of the ADCAP programme. HelpAge, 2018.
www.helpage.org
Children and child protection

INEE Minimum Standards for Education: Preparedness, Response, Recovery. INEE, 2010.
www.ineesite.org/en/minimum-standards
Minimum Standards for Child Protection in Humanitarian Action: Alliance for
Child Protection in Humanitarian Action, 2012. http://cpwg.net
Further reading
47
Further reading
Further reading
General protection: background and tools
Aide Memoire: For the Consideration of Issues Pertaining for the Protection of Civilians.
OCHA, 2016. https://www.unocha.org/sites/unocha/files/Aide%20Memoire%20
2016%20II_0.pdf
Enhancing Protection for Civilians in Armed Conflict and Other Situations of Violence.
ICRC, 2017. www.icrc.org/eng/resources/documents/publication/p0956.htm
FMR 53: Local communities: first and last providers of protection. University of Oxford and
Refugee Studies Centre, 2016. www.fmreview.org/community-protection.html
Giossi Caverzasio, S. Strengthening Protection in War: A Search for Professional
Standards. ICRC, 2001. https://www.icrc.org/en/publication/0783-strengthening-
protection-war-search-professional-standards
Growing the Sheltering Tree – Protecting Rights through Humanitarian Action –
Programmes & practices gathered from the field. IASC, 2002. www.global
protectioncluster.org/_assets/files/tools_and_guidance/IASC_Growing_
Sheltering_Tree_2002_EN.pdf
Operational Guidelines on the Protection of Persons in Situations of Natural
Disasters. IASC, 2011. www.ohchr.org/Documents/Issues/IDPersons/Operational
Guidelines_IDP.pdf
O’Callaghan, S. Pantuliano, S. Protective Action: Incorporating Civilian Protection into
Humanitarian Response. HPG Report 26. ODI, 2007. https://www.odi.org/sites/odi.
org.uk/files/odi-assets/publications-opinion-files/1640.pdf
Protection and Accountability to Affected Populations in the HPC (EDG Preliminary
Guidance Note). IASC, 2016. www.interagencystandingcommittee.org/system/
files/edg_-aap_protection_guidance_note_2016.pdf
Protection Mainstreaming Training & Sector-Specific Guidance. Global Protection
Cluster. www.globalprotectioncluster.org/en/areas-of-responsibility/protection-
mainstreaming
Safety with Dignity: A field manual for integrating community-based protection across
humanitarian programs. Action Aid, 2009. www.actionaid.org/sites/files/actionaid/
safety_with_dignity_actionaid_2009.pdf
Statement on the Centrality of Protection in Humanitarian Action. IASC, 2013. https://
interagencystandingcommittee.org/sites/default/files/centrality_of_protec-
tion_in_humanitarian_action_statement_by_iasc_princi.pdf
Slim, H. Bonwick, A. Protection – An ALNAP Guide for Humanitarian Agencies. ALNAP,
2005. www.alnap.org/resource/5263
Self-protection strategies and capacities

Local Perspectives on Protection: Recommendations for a Community-based
Approach to Protection in Humanitarian Action. Local to Global Protection, 2015.
www.local2global.info/wp-content/uploads/L2GP_pixi_Final_WEB.pdf
F1
Thematic Policy Document no 8 – Humanitarian Protection: improving protection

outcomes to reduce risks for people in humanitarian crises, page 24. DG ECHO, EC,
2016. ec.europa.eu/echo/sites/echo-site/files/policy_guidelines_humanitarian_
protection_en.pdf
Cash-based interventions
Guide for Protection in Cash-based Interventions. UNHCR and partners, 2015. www.
globalprotectioncluster.org/_assets/files/tools_and_guidance/cash-based-
interventions/erc-guide-for-protection-in-cash-based-interventions-web_en.pdf

Including Children with Disabilities in Humanitarian Action: Child Protection. UNICEF,
2017. training.unicef.org/disability/emergencies/protection.html
Need to Know Guidance: Working with Persons with Disabilities in Forced Displacement.
UNHCR, 2011. www.unhcr.org/4ec3c81c9.pdf
Washington Group on Disability Statistics. 2018. www.washingtongroup-disability.
com
Building Capacity for Disability Inclusion in Gender-based Violence Programming in
Humanitarian Settings: A Toolkit for GBV Practitioners. Women’s Refugee Commission &
International Rescue Committee, 2015. www.womensrefugeecommission.
org/?option=com_zdocs&view=document&id=1173
Ethical and safety recommendations for researching, documenting and moni-
toring sexual violence in emergencies. WHO, 2007. http://apps.who.int/iris/
bit stream/handle/10665/4370 9/978 92415956 81_eng.pdf;jsessionid=
9834DA17763D28859CAD360E992A223B?sequence=1
Gender-based Violence Against Children and Youth with Disabilities: A Toolkit for
Child Protection Actors. Women’s Refugee Commission, ChildFund International,
2016. www.womensrefugeecommission.org/populations/disabilities/research-
and-resources/1289-youth-disabilities-toolkit
Housing, land and property rights

Checklist of Housing, Land and Property Rights and Broader Land Issues Throughout
the Displacement Timeline from Emergency to Recovery. Global Protection Cluster,
Housing, Land and Property Area of Responsibility, 2009.
Handbook on Housing and Property Restitution for Refugees and Displaced Persons.
Implementing the “Pinheiro Principles”. Internal Displacement Monitoring Centre,
FAO, OCHA, Office of the UN High Commissioner for Human Rights, UN-Habitat
and UNHCR, 2007. www.unhcr.org/refworld/docid/4693432c2.html
Land and Natural Disasters: Guidance for Practitioners. UN Human Settlements
Programme. UN-Habitat, FAO, Global Land Tool Network and Early Recovery
Cluster, 2010. https://unhabitat.org/books/land-and-natural-disasters-guidance-
for-practitioners/
F2
Further reading
Internally displaced persons

Addressing Internal Displacement: A Framework for National Responsibility. Brookings
Institution – University of Bern Project of Internal Displacement, 2005.
https://www.brookings.edu/research/addressing-internal-displacement-a-
framework-for-national-responsibility/
Bagshaw, S. Paul, D. Protect or Neglect? Toward a More Effective United Nations Approach
to the Protection of Internally Displaced Persons. Brookings-SAIS Project on Internal
Displacement and UNOCHA, Interagency Internal Displacement Division, 2004.
https://www.brookings.edu/research/protect-or-neglect-toward-a-more-effective-
united-nations-approach-to-the-protection-of-internally-displaced-persons/
Framework on Durable Solutions for Internally Displaced Persons. IASC, 2010.
www.brookings.edu/research/iasc-framework-on-durable-solutions-for-
internally-displaced-persons/
Implementing the Collaborative Response to Situations of Internal Displacement:
Guidance for UN Humanitarian and/or Resident Coordinators and Country Teams. IASC,
2004. www.refworld.org/pdfid/41ee9a074.pdf
UN Guiding Principles on Internal Displacement. UN Economic and Social Council,
1998. www.unhcr.org/protection/idps/43ce1cff2/guiding-principles-internal-
displacement.html

Community-based Protection and Mental Health & Psychosocial Support. UNHCR, 2017.
www.unhcrexchange.org/communities/9159/contents/347734
Mental Health and Psychosocial Support (MHPSS) in Humanitarian Emergencies: What
Should Protection Programme Managers Know? IASC Reference Group on Mental
Health and Psychosocial Support, 2010. https://interagencystandingcommittee.
org/system/files/legacy_files/MHPSS%20Protection%20Actors.pdf
Older people
Humanitarian Action and Older Persons: An essential brief for humanitarian actors. WHO,
HelpAge International, IASC, 2008. www.globalprotectioncluster.org/_assets/
files/tools_and_guidance/IASC_HumanitarianAction_OlderPersons_EN.pdf
Children and child protection

Handbook for Professionals and Policymakers on Justice in matters involving child
victims and witnesses of crime. UNODC, 2009. https://www.unodc.org/documents/
justice-and-prison-reform/hb_justice_in_matters_professionals.pdf
Integrated Disarmament, Demobilization, and Reintegration Standards. UN-DDR, 2006.
www.unddr.org/iddrs.aspx
Inter-agency Guiding Principles on Unaccompanied and Separated Children. ICRC,
International Rescue Committee, Save the Children, UNICEF, UNHCR and World
Vision, 2004. www.icrc.org/eng/assets/files/other/icrc_002_1011.pdf
INSPIRE: Seven Strategies for Ending Violence against Children. WHO, 2016. www.who.
int/violence_injury_prevention/violence/inspire/en/
F3
Paris Principles and Commitments to Protect Children from Unlawful Recruitment or Use
by Armed Forces or Groups. UNICEF, 2007. https://www.unicef.org/protection/
57929_58012.html
Responding to the Worst Forms of Child Labour in Emergencies. CPWG, 2010. http://
cpwg.net/wp-content/uploads/sites/2/2014/12/Review_Responding_to-_
WFCL_in_Emergencies_final.pdf
HIV
Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for
Key Populations. Update. WHO, 2016. www.who.int/hiv/pub/guidelines/
keypopulations-2016/en/
Implementing Comprehensive HIV and STI Programmes with Transgender People:
Practical guidance for collaborative interventions. UNDP, 2016. www.undp.org/
content/undp/en/home/librarypage/hiv-aids/implementing-comprehensive-
hiv-and-sti-programmes-with-transgend.html
Implementing Comprehensive HIV and HCV Programmes with People Who Inject
Drugs: Practical guidance for collaborative interventions. UNODC, 2017. www.
unodc.org/unodc/en/hiv-aids/new/practical-guidance-for-collaborative-
interventions.html
Implementing Comprehensive HIV/STI Programmes with Sex Workers: Practical
approaches from collaborative interventions. WHO, 2013. www.who.int/hiv/pub/sti/
sex_worker_implementation/en/
Implementing Comprehensive HIV/STI Programmes with Men Who Have Sex with Men:
Practical guidance for collaborative interventions. UNFPA, 2015. www.who.int/hiv/
pub/toolkits/msm-implementation-tool/en/
Joint United Nations Statement on ending discrimination in health care
settings. WHO, 2017. www.who.int/mediacentre/news/statements/2017/
discrimination-in-health-care/en/
LGBTQI people and diverse sexual orientation, gender identity and

expression, and sex characteristics
Joint UN Statement on ending violence and discrimination against lesbian, gay, bisexual,
transgender and intersex (LGBTI) people. OHCHR, 2015. www.ohchr.org/EN/Issues/
Discrimination/Pages/JointLGBTIstatement.aspx
Mean Streets: Identifying and Responding to Urban Refugees’ Risks of Gender-Based
Violence – LGBTI Refugees. Women’s Refugee Commission, 2016. https://www.
womensrefugeecommission.org/gbv/resources/document/download/1284
Training Package on the Protection of LGBTI Persons in Forced Displacement. UNHCR,
2015. www.unhcrexchange.org/old/topics/15810/contents
The Yogyakarta Principles: Principles on the Application of International Human Rights
Law in Relation to Sexual Orientation and Gender Identity. International Commission of
Jurists, 2007. www.yogyakartaprinciples.org
Working with Lesbian, Gay, Bisexual, Transgender & Intersex Persons in Forced
Displacement. UNHCR, 2011. www.refworld.org/pdfid/4e6073972.pdf
F4
Core
Humanitarian
Standard
The Humanitarian Charter and Protection Principles directly support the Core Humanitarian Standard.
Together, these three chapters constitute the principles and foundations of the Sphere standards.
n da r d - C ore H
St a um
an
n 1 it a
r ia Humanitarian
9 response is
2
it a
r ia
Resources appropriate
an
and relevant. Humanitarian
n
are managed
response is
um
and used responsibly

effective and
St a
for their intended
- timely.
da rd - C ore H
purpose. Im
it y p
8 an ar
3
nda r
m
t ia
Staff are Humanitarian
Hu
li t y
supported to do their response strengthens
COMMUNITIES
d - C ore
job effectively, and local capacities and
are treated fairly AND PEOPLE avoids negative
-
and equitably. effects.

AFFECTED
-
BY CRISIS 4
ce
7
Ne
en
nd
ut
Humanitarian al Humanitarian
r
e
ep response is based
it y
n
actors continuously I nd
on communication,
St a
Hu
learn and improve.
-
participation and
pa
6 5 feedback. ma
Humanitarian
n
Complaints
n
ria
response is are welcomed

it a
coordinated and and addressed.

ria
it a n complementary. n
ma St a
Hu nda r
d - Core
The Core Humanitarian Standard (Figure 2)
Appendix: Guiding questions for monitoring Key actions and Organisational requirements (online)
50
Contents
One core standard with nine commitments........................................................................52
Commitment 1.........................................................................................................................54
Commitment 2.........................................................................................................................56
Commitment 3.........................................................................................................................59
Commitment 4.........................................................................................................................63
Commitment 5.........................................................................................................................66
Commitment 6.........................................................................................................................70
Commitment 7.........................................................................................................................73
Commitment 8.........................................................................................................................76
Commitment 9.........................................................................................................................80
Appendix: Guiding questions for monitoring key actions and
organisational responsibilities (online)
51
One core standard with nine

commitments
Many organisations and individuals are typically involved in a humanitarian
response. Some common elements and ways of working are therefore useful for
promoting an effective response. Without a common approach, outcomes may be
inconsistent and unpredictable.
The Core Humanitarian Standard on Quality and Accountability (CHS) sets out
nine Commitments that organisations and individuals involved in humanitarian
response can use to improve the quality and effectiveness of the assistance
they provide. It also facilitates greater accountability to communities and people
affected by crisis, staff, donors, governments and other stakeholders. Knowing
what humanitarian organisations have committed to will enable them to hold
those organisations to account. It is a voluntary framework for both individuals
and organisations.
The Standard applies both at the response and programme levels and in all phases
of a response. However, the nine Commitments are not intended to correspond to
any particular phase of the programme cycle. Some are more relevant to a certain
phase of the cycle, while others, such as communication with affected people, are
intended to apply throughout all phases.
The Core Humanitarian Standard, along with the Humanitarian Charter and
Protection Principles, forms a strong foundation within The Sphere Handbook
and supports all technical standards. Throughout the Handbook, there are cross-
references between the technical chapters and these foundations.
More detailed information on the Core Humanitarian Standard, including
resources to help users apply it in practice, can be found at corehumanitarian-
standard.org.
A unique structure
The Core Humanitarian Standard was developed through a collective effort
by the humanitarian sector to harmonise the core standards from Sphere, the
Humanitarian Accountability Partnership (HAP), People In Aid, and Groupe URD
into a single framework. It is now managed on behalf of the sector by Sphere, the
CHS Alliance and Groupe URD, who jointly hold the copyright.
Each of the nine commitments concentrates on a specific aspect of response.
Taken together, they form a solid approach to effective and accountable humani-
tarian action.
52
ONE CORE STANDARD WITH NINE COMMITMENTS – A UNIQUE STRUCTURE
The structure of the Core Humanitarian Standard differs slightly from that of the
other Sphere standards:
• The Commitment states what communities and people affected by crisis

can expect from organisations and individuals delivering humanitarian
assistance.
• The Quality criterion describes a situation where the Commitment is met
and how humanitarian organisation and staff should be working to meet the
Commitment.
• performance indicators measure progress in meeting the Commitment,
drive learning and improvement and allow for comparison across time
and location.
• Key actions and Organisational responsibilities describe what staff should
deliver and the policies, processes and systems that organisations need
to have in place to ensure their staff provide high-quality, accountable
humanitarian assistance.
• Guidance notes support the Key actions and Organisational responsibilities
with examples and additional information.
• Guiding questions support planning, evaluation and review activities ⊕ see
Appendix 1 (available online).
• References provide additional learning on specific issues.
The following chart shows how the Core Humanitarian Standard can be used at
different levels. Sphere, Groupe URD and the CHS Alliance propose complementary
tools which can be found at corehumanitarianstandard.org.
Global and policy levels
Dissemination Organisational level

and advocacy
Field level
Peer learning Support to Technical
CHS
and exchanges organisational & sectoral
implementation guidance
Support to Verification Methodological COMMITMENTS GUIDANCE

collective (and certification) guidance for project & CRITERIA NOTES &
INDICATORS
accountability management
& evaluation
Using the Core Humanitarian Standard (Figure 3)
53
Commitment 1
Communities and people affected by crisis receive assistance appropriate to
their needs.
Quality criterion
Humanitarian response is appropriate and relevant.
Performance indicators
1. Communities and people affected by crisis consider that the response takes
account of their specific needs, culture, and preferences.
2. The assistance and protection provided correspond with assessed risks,
vulnerabilities and needs.
3. The response takes account of the capacities, skills and knowledge of people
requiring assistance and protection.
Key actions
1.
1.1 Conduct a systematic, objective and ongoing analysis of the context and
stakeholders.
•• Assess the role and capacity of local government and other political and
non-political actors, as well as the impact of the crisis on them.
•• Assess existing local capacities (material, human, markets) to meet priority
assistance and protection needs, understanding that these will change
over time.
•• Cross-check and verify information, acknowledging that assessment data
will initially be imperfect, but should not impede life-saving actions.
•• Assess the safety and security of affected, displaced and host populations to
identify threats of violence and any forms of coercion, denial of subsistence
or denial of basic human rights.
•• Assess gender-related and power dynamics, as well as social marginalisation,
to define a more effective and sustainable response.
•• Coordinate with others to avoid burdening communities with multiple
assessments. Joint assessments and findings should be shared with
interested agencies, government and affected populations.
1.
1.2 Design and implement appropriate programmes based on an impartial
assessment of needs and risks and an understanding of the vulnerabilities
and capacities of different groups.
•• Assess the protection and assistance needs of women, men, children and
adolescents, of those in hard-to-reach locations and at-risk groups such as
persons with disabilities, older people, socially isolated individuals, female-
headed households, ethnic or linguistic minorities and stigmatised groups
(for example, people living with HIV).
54
CORE HUMANITARIAN STANDARD – Commitment 1
1.
1.3 Adapt programmes to changing needs, capacities and context.
•• Monitor the political situation and adapt stakeholder analysis and security.
•• Monitor epidemiological and other data regularly to inform ongoing
decision-making and prioritise life-saving interventions.
•• Remain flexible enough to redesign any intervention in response to changing
needs. Confirm that donors agree with programme changes as needed.
Organisational responsibilities
1.
1.4 Policies commit to providing impartial assistance based on the needs and
capacities of communities and people affected by crisis.
•• Organisations maintain policies, processes and systems that support a
commitment to humanitarian principles and inclusiveness.
•• All staff understand their responsibilities and how they may be held to
account.
•• Organisations share these policies transparently with other stakeholders.
1.
1.5 Policies set out commitments which take into account the diversity of
communities, including disadvantaged or marginalised people, and to collect
disaggregated data.
•• Required levels of data disaggregation for assessment and reporting are
clearly outlined.
1.
1.6 Processes are in place to ensure an appropriate ongoing analysis of
the context.
•• Humanitarian workers have management support to acquire the knowl-
edge, skills, behaviours and attitudes necessary to manage and carry out
assessments.
Guidance notes
Assessment and analysis is a process, not a single event. As time allows, in-depth
analysis should be carried out. The capacities and needs of affected people and
communities should not be assumed but identified through assessments that
engage them in an ongoing discussion to find appropriate responses.
Consider providing basic training in psychological first aid for staff involved in
assessments. This can help the staff manage people who become distressed
during an assessment.
Ensure specialised assessments for groups potentially facing protection risks.
Specific assessments with women, men, boys and girls to understand their
exposure to violence, discrimination and other harms are an example.
Impartial assessment: Acting impartially does not mean treating all people
the same. Providing rights-based assistance requires an understanding of
55
differing capacities, needs and vulnerabilities. People may be vulnerable

because of discrimination based on individual factors such as age, sex, disability,
health status, sexual orientation or gender identity, or because they are caring
for others who are vulnerable.
Vulnerability: Social and contextual factors also contribute to people’s vulnerability.
These include discrimination and marginalisation, social isolation, environmental
degradation, climate variability, poverty, lack of land tenure, poor governance,
ethnicity, class, caste and religious or political affiliations.
Existing capacity: People, communities, organisations and authorities affected
by crisis already possess relevant skills, knowledge and capacity to cope with,
respond to and recover from crises. To uphold the right to life with dignity, actively
engage affected people in decisions that affect them. Targeted efforts may need to
be undertaken to strengthen participation of typically under-represented groups,
such as women, children, older people, people with disabilities, and linguistic or
ethnic minorities.
Data disaggregation: This is important to understand the impact of actions or
events on different groups. At a minimum, good practice encourages disaggregation
by sex, age and disability. Additional factors should be based on context.
Analysis of disaggregated data is necessary to using standards in context and
to monitoring. Good use of disaggregated data can show who has been most
affected, who is able to access assistance and where more needs to be done to
reach an at-risk population ⊕ see What is Sphere?.
Ongoing analysis and effective use of the data: Human resources systems should
be flexible enough to recruit and deploy assessment teams rapidly. Allocate
programme budgets and resources according to need. Funding should support
ongoing analysis of assistance and protection needs and the adaptation and
correction of programmes, including measures to facilitate access (such as
outreach mechanisms, accessibility of facilities and communication).
Commitment 2
Communities and people affected by crisis have access to the humanitarian
assistance they need at the right time.
Quality criterion
Humanitarian response is effective and timely.
1. Communities and people affected by crisis, including the most vulnerable
groups, consider that the timing of the assistance and protection they
receive is adequate.
56
2. Communities and people affected by crisis consider that the response meets
their needs.
3. Monitoring and evaluation reports show that the humanitarian response
meets its objectives in terms of timing, quality and quantity.
Key actions
1.
2.1 Design programmes that address constraints so that the proposed action is
realistic and safe for communities.
•• Clearly identify and state any limitations if it is not possible to assess and
meet the needs of a specific area or population group, including hard-to-
reach locations.
•• Prioritise support to local response capacity in advance where contingency
planning shows areas or populations are vulnerable and may prove hard to
access in the future.
1.
2.2 Deliver humanitarian response in a timely manner, making decisions and
acting without unnecessary delay.
•• Be aware of living conditions, cultural practices, seasons, agricultural
calendars and other factors that influence providing the right services at the
right time.
•• Include time frames for delivery and monitoring systems in programme
plans; anticipate and flag delays.
•• Acknowledge that decisions will be made based on imperfect knowledge
in the early stages of an acute crisis and refine decisions as information
becomes available.
•• Coordinate with others to develop shared strategies to address collective
issues that block timely assistance.
1.
2.3 Refer any unmet needs to those organisations with the relevant technical
expertise and mandate, or advocate for those needs to be addressed.
•• This includes unmet information needs as well as protection and assis-
tance needs.
1.
2.4 Use relevant technical standards and good practice employed across the
humanitarian sector to plan and assess programmes.
•• Apply national technical standards, where these exist, adapted to the
humanitarian context.
•• Coordinate with relevant stakeholders to advocate for the use of globally
agreed standards to complement national ones (including Sphere and
partner standards in related sectors).
57
1.
2.5 Monitor the activities, outputs and outcomes of humanitarian responses in
order to adapt programmes and address poor performance.
•• Define time-bound and context-specific performance indicators.
Review them on a regular basis to measure progress towards meeting
assistance and protection needs.
•• Include progress against objectives and performance indicators, in addition
to activities and outputs (such as number of facilities built). Monitor project
outcomes and desired results such as use of facilities or changes in practice.
•• Review systems regularly so that only useful information is collected,
with updated contextual information (such as local market function,
change in security).
1.
2.6 Programme commitments are in line with organisational capacities.
•• Policies reflect the importance of using agreed humanitarian technical

quality standards and developing expertise in chosen areas of intervention.
•• Acknowledge the conditions under which the organisation may need to
provide services outside this area of expertise until others can do so.
1.
2.7 Policy commitments ensure:
a. systematic, objective and ongoing monitoring and evaluation of

activities and their effects;
b. evidence from monitoring and evaluations is used to adapt and improve
programmes; and
c. timely decision-making, with resources allocated accordingly.
Guidance notes
Addressing constraints and realistic programming: Where an organisation cannot
access a population or meet identified needs, it has a responsibility to refer these
needs to appropriate actors (including government, non-government actors) ⊕ see
Protection Principle 3.
Use forecasts and early warning systems for contingency planning before a crisis
to help communities, authorities and agencies respond quickly when needed.
This will also allow affected people to protect their assets before their lives and
livelihoods are at risk.
Develop decision-making processes that are flexible enough to respond to new
information from ongoing assessments. Within an organisation, delegate decisions
and resources as close to the implementation site as possible.
Document decisions and decision-making processes to demonstrate transparency.
Base the processes on consultation, meaningful participation and coordination
with others ⊕ see Commitment 6.
58
Monitoring activities, outputs and outcomes: Monitoring informs project revisions,

verifies application of selection criteria and confirms whether aid is reaching
the people most in need. Document any programme changes that result from
monitoring and establish monitoring systems that involve and rely on affected
people and key stakeholders ⊕ see Commitment 7.
Use common response-wide monitoring indicators where available.
Organisational decision-making: Both the responsibilities and processes for
decision-making within organisations must be clearly defined and understood,
including who is responsible, who will be consulted and what information is
needed to inform decision-making.
Organisational policies, processes and systems: Organisations should document
how humanitarian action improves outcomes, using systematic and rigorous
monitoring and evaluation. Show how data from monitoring and evaluation is
used to adapt programmes, policies and strategies, strengthen preparedness and
improve performance in a timely manner ⊕ see Commitment 7. This may include an
emergency response fund or being able to recruit or deploy qualified staff quickly
when needed.
Commitment 3
Communities and people affected by crisis are not negatively affected and are
more prepared, resilient and less at-risk as a result of humanitarian action.
Quality criterion
Humanitarian response strengthens local capacities and avoids negative effects.
1. Communities and people affected by crisis consider themselves better able
to withstand future shocks and stresses, as a result of humanitarian action.
2. Local authorities, leaders and organisations with responsibilities for
responding to crises consider that their capacities have been increased.
3. Communities and people affected by crisis, including vulnerable and
marginalised individuals, do not identify negative effects resulting from
humanitarian action.
Key actions
1.
3.1 Ensure programmes build on local capacities and work towards improving
the resilience of communities and people affected by crisis.
•• Design services (for example, drought management and flood-, hurricane- or
earthquake-resistant structures) that reduce the impact of hazards.
•• Support self-help initiatives and community preparedness actions.
59
1.
3.2 Use the results of any existing community hazard and risk assessments and
preparedness plans to guide activities.
•• Understand and address needs and capacities of different groups who are
exposed to different levels of risk.
1.
3.3 Enable the development of local leadership and organisations in their
capacity as first responders in the event of future crises, taking steps to
ensure that marginalised and disadvantaged groups are appropriately
represented.
•• Work with municipal authorities and local government as much as possible.
•• Advocate that local actors are treated as equal partners with autonomy to
design and/or lead a response.
•• Support the initiatives of local groups and organisations, as the
platform for learning and capacity-building to strengthen first response in
future crises.
•• Hire local and national staff, considering diversity within the population,
instead of expatriates wherever possible.
1.
3.4 Plan a transition or exit strategy in the early stages of the humanitarian
programme that ensures longer-term positive effects and reduces the risk
of dependency.
•• Provide support to strengthen existing state and community systems, rather
than establish parallel efforts that will not last beyond the duration of the
response.
1.
3.5 Design and implement programmes that promote early disaster recovery
and benefit the local economy.
•• Take steps to restore social services, education, markets, transfer
mechanisms and livelihood opportunities that cater to the needs of
vulnerable groups.
•• Fully consider market conditions when analysing which form of assistance
(cash, voucher, or in-kind) will have the greatest positive outcome.
•• Buy goods and services locally when possible.
•• Mitigate negative repercussions on the market to the extent possible.
1.
3.6 Identify and act upon potential or actual unintended negative effects in a
timely and systematic manner, including in the areas of:
a. people’s safety, security, dignity and rights;
b. sexual exploitation and abuse by staff;
c. culture, gender, and social and political relationships;
d. livelihoods;
e. the local economy; and
f. the environment.
60
1.
3.7 Policies, strategies and guidance are designed to:
a. prevent programmes having any negative effects such as, for example,
exploitation, abuse or discrimination by staff against communities and
people affected by crisis; and
b. strengthen local capacities.
1.
3.8 Systems are in place to safeguard any personal information collected from
communities and people affected by crisis that could put them at risk.
•• Establish clear and comprehensive policies on data protection, including
electronic registration and distribution systems.
•• Inform those receiving aid about their rights in relation to data protection,
how they can access the personal information that an organisation
holds about them and how to raise concerns they have about misuse of
information.
Guidance notes
Community resilience and local leadership: Communities, local organisations and
authorities are the first to act in a crisis and have in-depth knowledge of the
situation and specific needs. These local actors should be equal partners and
given autonomy in designing or leading a response. This requires a commitment by
international and local agencies to adapt their way of working and engage in open
dialogue and constructive criticism. Local financial infrastructure/services should
be used wherever possible, instead of creating new parallel systems.
Transition and exit strategy: In collaboration with the authorities and affected
population, design services as soon as possible that will continue after the emer-
gency programme has finished (for example, introduce cost-recovery measures,
use locally available materials or strengthen local management capacity).
Negative effects and “do no harm”: The high value of aid resources and the powerful
position of humanitarian workers can lead to exploitation and abuse, competition,
conflict, and misuse or misappropriation of aid. Aid can undermine livelihoods
and market systems, drive resource conflict and amplify unequal power relations
between different groups. Anticipate these potential negative effects, monitor
and take actions to prevent them if possible.
Be aware of cultural practices that may have negative effects on some groups.
Examples include: biased targeting of girls, boys or specific castes; unequal
education opportunities for girls; refusing immunisations; and other forms of
discrimination or preferential treatment.
Safe and responsive feedback and complaints mechanisms can reduce abuse and
misuse. Staff should welcome and seek out suggestions and complaints. Staff
61
should be trained in how to exercise confidentiality and refer sensitive information,

such as disclosures of exploitation and abuse.
Sexual exploitation and abuse by staff: All staff share a responsibility to prevent
exploitation and abuse. Staff members have a responsibility to report any abuse
they suspect or witness, whether within their own organisation or outside. Note
that children (girls in particular) are often highly vulnerable, and policies should
explicitly protect children from exploitation and abuse ⊕ see Commitment 5.
Environmental concerns: Humanitarian response can cause environmental degra-
dation (for example, soil erosion, depletion or pollution of groundwater, overfishing,
waste production and deforestation). Environmental degradation can amplify a
crisis or levels of vulnerability and reduces people’s resilience to shocks.
Measures to reduce environmental degradation include reforestation, rainwater
harvesting, efficient use of resources and ethical procurement policies and
practices. Major construction activities should only be performed following an
environmental assessment ⊕ see Commitment 9.
Organisational policies to prevent negative effects and strengthen local capacities:
Organisations are encouraged to have a clearly documented risk management
policy and system in place. Non-governmental organisations (NGOs) that fail to
systematically tackle unethical behaviour or corruption via their own anti-bribery
policies and procedures and through collective action with other NGOs increase
corruption risks for other actors.
Policies and procedures should reflect a commitment to the protection of vulner-
able people and outline ways to prevent and investigate the abuse of power.
Careful recruitment, screening and hiring practices can help to reduce the risk of
staff misconduct, and codes of conduct should make it clear what practices are
forbidden. Staff should formally agree to adhering to these codes and be made
aware of the sanctions they will face if they fail to do so ⊕ see Commitment 8.
Safeguarding personal information: All personal information collected from
individuals and communities must be treated as confidential. This is particularly
the case in handling protection-related data, reported violations, complaints of
abuse or exploitation, and gender-based violence. Systems that ensure confi-
dentiality are essential to prevent further harm ⊕ see Protection Principles and
The increasing use of electronic registration and distribution systems in
humanitarian response highlights the need for clear and comprehensive
policies on data protection. Agreements obliging third parties such as banks
and commercial organisations to safeguard information are essential. Clear
guidance about the collection, storage, use and disposal of data, aligned with
international standards and local data protection laws, is important. Systems
to mitigate the risk of data being lost should be put in place. Data should be
destroyed once no longer required.
62
Commitment 4
Communities and people affected by crisis know their rights and entitlements,
have access to information and participate in decisions that affect them.
Quality criterion
Humanitarian response is based on communication, participation and feedback.
1. Communities and people affected by crisis are aware of their rights and
entitlements.
2. Communities and people affected by crisis consider that they have timely
access to clear and relevant information, including about issues that may put
them at further risk.
3. Communities and people affected by crisis are satisfied with the opportu-
nities they have to influence the response.
4. All staff are trained and provided with guidance on the rights of the affected
population.
Key actions
1.
4.1 Provide information to communities and people affected by crisis about the
organisation, the principles it adheres to, how it expects its staff to behave,
the programmes it is implementing and what they intend to deliver.
•• Consider information itself as a key element of protection. Without accurate
information about the assistance and their entitlements, people may
become vulnerable to exploitation and abuse ⊕ see Protection Principle 1.
•• Communicate clearly what behaviour people can expect from humanitarian
workers and how they can complain if they are not satisfied.
1.
4.2 Communicate in languages, formats and media that are easily understood,
respectful and culturally appropriate for different members of the community,
especially vulnerable and marginalised groups.
•• Use existing communication systems and consult with people on their
communications preferences. Consider the degree of privacy required for
different formats and media.
•• Ensure that communications technology, new and old, is used effectively
and safely.
1.
4.3 Ensure representation is inclusive, involving the participation and engage-
ment of communities and people affected by crisis at all stages of the work.
•• Give attention to groups or individuals historically excluded from power
and decision-making processes. Systematically consider ethical ways of
63
engaging with these individuals and groups to respect dignity and avoid
any increased stigma.
•• Consider the balance between direct community participation and indirect
representation by elected representatives through the various stages
of response.
1.
4.4 Encourage and facilitate communities and people affected by crisis to provide
feedback on their level of satisfaction with the quality and effectiveness of
the assistance received, paying particular attention to the gender, age and
diversity of those giving feedback.
•• Train staff to gain and maintain people’s trust, know how to respond to
both positive and negative feedback and observe the reactions of different
community members to the way services are provided.
•• Integrate feedback collection into a broader approach across organisations
or sectors to review, analyse and act on the feedback.
•• Share response to the feedback with the community.
1.
4.5 Policies for information sharing are in place, and promote a culture of open
communication.
•• Define and document processes for sharing information.
•• Strive to share organisational information about successes and failures
openly with a range of stakeholders to promote a system-wide culture of
openness and accountability.
1.
4.6 Policies are in place for engaging communities and people affected by crisis,
reflecting the priorities and risks they identify in all stages of the work.
•• Outline how staff members are trained and encouraged to facilitate commu-
nity engagement and decision-making, listen to diverse communities of
affected people and manage negative feedback.
•• Design policies and strategies to help create space and time for community
dialogues, decision-making and self-help.
1.
4.7 External communications, including those used for fundraising purposes,
are accurate, ethical and respectful, presenting communities and people
affected by crisis as dignified human beings.
•• Share information based on risk assessment. Consider potential harm to
the population, such as when sharing information about cash distributions
or demographics of specific settlements, which can put people at risk of
being attacked.
•• Exercise care when making use of stories and images that discuss and depict
affected people, as this can be an invasion of their privacy and a breach of
confidentiality if their permission is not sought ⊕ see Protection Principle 1 on
informed consent.
64
Guidance notes
Sharing information with communities: Sharing accurate, timely, understandable
and accessible information strengthens trust, deepens levels of participation and
improves the impact of a project. It is key to being transparent. Sharing financial
information with communities can improve cost-effectiveness and help communi-
ties to identify and highlight waste or fraud.
If an organisation does not share information appropriately with the people it
aims to assist, misunderstandings and delays, inappropriate projects that waste
resources, and negative perceptions about the organisation can develop. This can
generate anger, frustration and insecurity.
Effective, safe, accessible and inclusive communication: Different groups have
different communication and information needs and sources. They may need time
talking among themselves in a safe, private setting to process the information and
its implications.
Informed consent: Be aware that some people may express consent without fully
understanding the implications. This is not ideal, but a degree of consent and
participation may initially have to be assumed based on expressed willingness to
take part in project activities, observation, knowledge, or legal or other documents
(such as contractual agreements with the community) ⊕ see Protection Principle 1.
Participation and engagement: Consult affected people and local institutions
early in the response to build on existing knowledge and develop positive,
respectful relations. Early consultation can be a better use of time than fixing
inappropriate decisions later. In the early stages of an acute response, consul-
tation might only be possible with limited numbers of affected people. Over
time, there will be more opportunities for more people and groups to become
involved in decision-making.
Be aware that in some conflict settings, encouraging group discussions and
decision-making could be seen as a form of political organising and could harm
local people. Consider various methods to enhance community engagement with
the feedback system, including the use of community scorecards.
Feedback: Formal feedback can be sought through specific assessments (using
group discussions or interviews), post-distribution monitoring, or questionnaires.
Informal feedback received during daily interaction should also be used to develop
trust and improve programmes on an ongoing basis. Obtain feedback on whether
women, men, girls and boys feel respected and satisfied with their influence over
decision-making. People may be satisfied with the aid delivered, but dissatisfied
with their influence on decision-making.
People may fear that critical feedback will have negative repercussions. There
may also be cultural reasons why criticism of an intervention is unacceptable.
Explore different methods of providing informal and formal feedback, including
methods for confidentially sharing the feedback.
65
Design feedback mechanisms with other agencies and ensure they are accessi-
ble to all people. They should be seen as separate from complaints mechanisms
that address serious infringements of practice or behaviour ⊕ see Commitment 5,
although in practice there is usually an overlap in the types of feedback and
complaints received. Acknowledge and follow up on the feedback received and
adapt the programme when appropriate. Integrate feedback mechanisms into
organisations’ monitoring and evaluation systems.
Promoting a culture of open communication: Organisations should publicly state (on
their website or in promotional material that is accessible by affected people) any
specific interests such as political or religious identity. This allows stakeholders
to better understand the nature of the organisation and its likely affiliations
and policies.
Organisational commitment to participation and listening to communities:
Gender and diversity policies can help to promote the values and commitments
of the organisation and provide concrete examples of expected behaviour.
Feedback from affected people should also inform strategy and programme
development.
Restricting information, confidentiality and non-disclosure: Not all information can
or should be shared with all stakeholders. Consider how the collection of informa-
tion that can identify groups (demographics) or individuals may cause or increase
people’s vulnerability or create new threats to their protection ⊕ see Protection
Principles.
An ethical approach to external communications: Fundraising material and photo-
graphs taken out of context can often be misleading and can also increase protec-
tion risks. Policies and guidelines relating to external communications should be
available to all staff and can help to ensure that mistakes are not made.
Details attached to images and included in stories must not allow people
(particularly children) to be traced to his or her home or community. Geotagging
of images should be disabled when taking photographs.
Commitment 5
Communities and people affected by crisis have access to safe and
responsive mechanisms to handle complaints.
Quality criterion
Complaints are welcomed and addressed.
1. Communities and people affected by crisis, including vulnerable and marginalised
groups, are aware of complaints mechanisms established for their use.
66
2. Communities and people affected by crisis consider the complaints response

mechanisms accessible, effective, confidential and safe.
3. Complaints are investigated, resolved and results fed back to the complain-
ant within the stated time frame.
Key actions
1.
5.1 Consult with communities and people affected by crisis on the design,
implementation and monitoring of complaints processes.
•• Disaggregate by sex, age and disability, as these criteria may influence
people’s views on access and obstacles to complaints mechanisms.
•• Agree on how complaints can be submitted, what may prevent people
and staff from complaining, and how they wish to receive the response to
complaints. Consider how complaints will be recorded and tracked and how
what is learned from them will be incorporated into future planning.
•• Explore joint complaints mechanisms with other agencies, partners and
third-party contractors.
•• Train staff on the complaints mechanism.
1.
5.2 Welcome and accept complaints, and communicate how the mechanism can
be accessed and the scope of issues it can address.
•• Consider an information campaign to help raise awareness of the system and
procedures, during which people can ask further questions about how it will work.
1.
5.3 Manage complaints in a timely, fair and appropriate manner that prioritises
the safety of the complainant and those affected at all stages.
•• Deal with each complaint individually, even if many cover similar issues.
•• Provide a response within a specified time frame. The complainant should
know when to expect a response.
•• Consider community management or engagement in the complaints-handling
system.
1.
5.4 The complaints response process for communities and people affected by
crisis is documented and in place. The process should cover programming,
sexual exploitation and abuse, and other abuses of power.
•• Keep records of how the complaints mechanism is set up, decision
criteria, all complaints made, how they were responded to and within
what time frame.
•• Take care to ensure that information on complaints is kept confidential, in
strict accordance with data protection policies.
•• Work with other organisations on complaints mechanisms, as this may be
less confusing for communities and staff.
67
1.
5.5 An organisational culture in which complaints are taken seriously and acted
upon according to defined policies and processes has been established.
•• Publicly share policies which relate to an organisation’s duty of care to the
people it aims to assist, its codes of conduct and how it will protect potentially
vulnerable groups such as women, children and people with disabilities.
•• Establish formal investigation procedures that adhere to the principles of
confidentiality, independence and respect. Conduct investigations in a thorough,
timely and professional manner, meeting legal standards and local labour law
requirements. Provide training to designated managers on investigations and
on handling staff misconduct, or provide access to specialist advice.
•• Include a grievance procedure and whistleblowing policy to deal with staff
complaints, and make staff aware of them.
1.
5.6 Communities and people affected by crisis are fully aware of the expected
behaviour of humanitarian staff, including organisational commitments
made on the prevention of sexual exploitation and abuse.
•• Explain the complaints process to communities and staff. Include mecha-
nisms for both sensitive issues (such as those relating to corruption, sexual
exploitation and abuse, gross misconduct or malpractice) and non-sensitive
information (such as challenges to the use of selection criteria).
1.
5.7 Complaints that do not fall within the scope of the organisation are referred
to a relevant party in a manner consistent with good practice.
•• Clarify guidance on which complaints fall within the organisation’s remit, and
when and how to refer to other service providers.
Guidance notes
Designing a complaints mechanism: Social and power dynamics must be assessed
before deciding on the best way to interact with communities. Pay attention to the
needs of older people, women and girls, boys and men, persons with disabilities
and others who might be marginalised. Ensure they have a say in the design and
implementation of complaints systems.
Raising awareness about how to make a complaint: Time and resources will be
needed to ensure that affected people know what services, staff attitudes and
behaviour they can expect from humanitarian organisations. They should also
know what to do and where to make a complaint if a humanitarian organisation
has failed to meet these commitments.
The mechanism should be designed so that people may be assured that they can
always make a complaint confidentially and without fear of retaliation.
Manage expectations, as communities may believe that the complaints process
can solve all their problems. This can generate frustration and disappointment if
the expected changes are outside the control of the agency.
68
Managing complaints: Explain clearly to the complainant when the complaint falls
outside the control and responsibility of the organisation. Where possible and in
agreement with the complainant, refer the complaint to the appropriate organisation.
Coordinate with other agencies and sectors to ensure this functions effectively.
Only trained staff should investigate allegations of sexual exploitation and abuse
by humanitarian workers.
Confidential referral for additional care and support (such as mental health and
psychosocial support, or other healthcare) should be provided for complainants
according to their wishes.
Anonymous and malicious complaints present specific challenges because
their source is unknown. They may be a warning signal to the organisation
of underlying discontent, and any follow-up will need to investigate whether
there is any previously unacknowledged cause for complaint.
Protecting complainants: Take care when deciding who needs to know what
information within the organisation. People reporting sexual abuse may
face social stigma and real danger from perpetrators and their own families.
Design a mechanism which ensures that complaints will be treated confiden-
tially. A whistleblowing policy should be in place to protect staff who highlight
concerns about programmes or the behaviour of colleagues.
Data protection policies should cover how long specific types of information should
be kept, in accordance with relevant data protection laws.
Complaints-handling process: Ensure that both the organisation’s staff and
the communities it serves have the opportunity to report complaints. Such
complaints can be seen as an opportunity to improve the organisation and its
work. Complaints can indicate the impact and appropriateness of an intervention,
potential risks and vulnerabilities, and the degree to which people are satisfied
with the services provided.
Sexual exploitation and abuse (SEA) of people affected by crisis: An organisa-
tion and its senior management are responsible for ensuring that complaints
mechanisms and procedures are in place, and are safe, transparent, accessible
and confidential. Where appropriate, organisations should consider including
specific statements about cooperating with investigations into SEA cases in
their partnership agreements.
Organisational culture: Managers and senior staff should model and promote
a culture of mutual respect between all staff, partners, volunteers and people
affected by crisis. Their support for the implementation of community complaints
mechanisms is vital. Staff should be aware of how to handle complaints or allega-
tions of abuse. In the case of criminal activity or where international law has been
broken, staff should know how to contact the appropriate authorities. Organisations
working with partners should agree on how they will raise and handle complaints
(including against each other).
69
Staff behaviour and codes of conduct: Organisations should have a staff code
of conduct that is endorsed by senior management and made public. A child
safeguarding policy should apply to all staff and partners, and inductions
and training should be provided on expected standards of behaviour. Staff
should know and understand the consequences of breaching the code of
conduct ⊕ see Commitments 3 and 8.
Commitment 6
Communities and people affected by crisis receive coordinated, complementary
assistance.
Quality criterion
Humanitarian response is coordinated and complementary.
1. Organisations minimise gaps and overlaps identified by affected communi-
ties and partners through coordinated action.
2. Responding organisations – including local organisations – share relevant
information through formal and informal coordination mechanisms.
3. Organisations coordinate needs assessments, delivery of humanitarian aid
and monitoring of aid implementation.
4. Local organisations report adequate participation and representation in
coordination mechanisms.
Key actions
1.
6.1 Identify the roles, responsibilities, capacities and interests of different
stakeholders.
•• Consider collaboration to optimise the capacity of communities,
host governments, donors, private sector and humanitarian organ-
isations (local, national, international) with different mandates and
expertise.
•• Suggest and lead joint assessments, trainings and evaluations across
organisations and other stakeholders to ensure a more coherent
approach.
1.
6.2 Ensure humanitarian response complements that of national and local
authorities and other humanitarian organisations.
•• Recognise that the overall planning and coordination of relief efforts is
ultimately the responsibility of the host government. Humanitarian
organisations have an essential role to play in supporting the state’s
response and coordination function.
70
1.
6.3 Participate in relevant coordination bodies and collaborate with others in
order to minimise demands on communities and maximise the coverage and
service provision of the wider humanitarian effort.
•• Advocate for the application of and adherence to recognised quality
standards and guidelines through coordination. Use coordination bodies
to contextualise humanitarian standards, especially the indicators, to
collectively monitor and evaluate activities and the overall response.
•• Determine the scope of activities and commitments, as well as any
overlap with other coordination bodies and how this will be managed,
for example in relation to accountability, gender and protection
coordination.
1.
6.4 Share necessary information with partners, coordination groups and other
relevant actors through appropriate communication channels.
•• Respect the use of local language(s) in meetings and other communications.
Examine barriers to communication so that local stakeholders are enabled
to participate.
•• Communicate clearly and avoid jargon and colloquialisms, especially when
other participants do not speak the same language.
•• Provide interpreters and translators if needed.
•• Consider the location of meetings to allow local actors to participate.
•• Work with networks of local civil society organisations to ensure their
members’ contributions are included.
1.
6.5 Policies and strategies include a clear commitment to coordination and
collaboration with others, including national and local authorities, without
compromising humanitarian principles.
•• Include coordination in organisational policies and resourcing strategies.
The organisation should provide a statement on how it will engage with
partners, host authorities and other humanitarian or non-humanitarian
actors.
•• Staff representing agencies in coordination meetings should have the
appropriate information, skills and authority to contribute to planning and
decision-making. Clearly articulate coordination responsibilities in staff job
descriptions.
1.
6.6 Work with partners is governed by clear and consistent agreements that
respect each partner’s mandate, obligations and independence, and recog-
nises their respective constraints and commitments.
•• Local and national organisations engage or collaborate with partners with
a shared understanding of each other’s organisational mandate and mutual
roles and responsibilities, for effective and accountable action.
71
Guidance notes
Working with the private sector: The private sector can bring commercial efficiencies,
complementary expertise and resources to humanitarian organisations. At the very
least, information sharing is required to avoid duplication and to promote humani-
tarian good practice. Ensure that the partnering businesses have committed to core
human rights and do not have a history of perpetuating inequalities or discrimina-
tory practices. Partnerships with the private sector should ensure explicit benefits
for people affected by crisis, while recognising that private sector actors may have
additional objectives of their own.
Civil–military coordination: Humanitarian organisations must remain clearly distinct
from the military to avoid any real or perceived association with a political or military
agenda that could compromise the agencies’ impartiality, independence, credibility,
security and access to affected populations.
The military has particular expertise and resources, including those associated
with security, logistics, transport and communication. However, any association
with the military must be in the service of and led by humanitarian agencies and
according to endorsed guidelines ⊕ see What is Sphere? Humanitarian Charter and
Protection Principles. Some organisations will maintain minimum dialogue to ensure
operational efficiency, while others may establish stronger links.
The three key elements of civil–military coordination are information sharing,
planning and division of tasks. Dialogue should take place throughout, in every
context and at all levels.
Complementary assistance: Local organisations, local authorities and civil society
networks have a significant amount of context-specific experience. They may need
support in re-establishing themselves following the effects of a crisis and need to
be engaged and represented in coordination of the response effort.
Where authorities are a party to the conflict, humanitarian actors should use their
judgement regarding the authorities’ independence, keeping the interests of the
affected populations at the centre of their decision-making.
Coordination: Cross-sectoral coordination can address people’s needs holistically
rather than in isolation. For example, coordination on mental health and psycho-
social supports must be done across the health, protection and education sectors,
such as through a technical working group made up of these specialists.
Coordination leaders have a responsibility to ensure that meetings and infor-
mation sharing are well managed, efficient and results-orientated. Local actors
may not participate in coordination mechanisms if they seem to be relevant only
to international agencies, due to language or location. National and sub-national
coordination mechanisms may be required and should have clear reporting lines.
Participation in coordination mechanisms before a disaster establishes relation-
ships and enhances coordination during a response. Link emergency coordination
72
structures with longer-term development plans and coordination bodies where

they exist.
International interagency mechanisms for the coordination of emergencies
should support national coordination mechanisms. In refugee assistance, the
refugee coordination mechanism should be that used by UNHCR.
Sharing information (including financial): between different stakeholders and
different coordination mechanisms makes it more likely that programme gaps or
duplication will be identified.
Working with partners: Different types of arrangements may exist with part-
ners, ranging from the purely contractual to shared decision-making and
shared resources. Respect the mandate and vision of the partner organisation
and its independence. Identify opportunities for mutual learning and development.
Identify what both parties stand to gain from the partnership as they increase
their knowledge and capacities and ensure better response preparedness and
more varied response options.
Longer-term collaborations between local and national civil society organisations
and international organisations can allow all partners to increase their knowl-
edge and capacities, and ensure better response preparedness and more varied
response options.
Commitment 7
Communities and people affected by crisis can expect delivery of improved
assistance as organisations learn from experience and reflection.
Quality criterion
Humanitarian actors continuously learn and improve.
1. Communities and people affected by crisis identify improvements to the
assistance and protection they receive over time.
2. Improvements are made to assistance and protection interventions as a
result of the learning generated in the current response.
3. The assistance and protection provided reflects learning from other responses.
Key actions
1.
7.1 Draw on lessons learned and prior experience when designing programmes.
•• Design monitoring systems that are simple and accessible, recognising that
information should be representative of different groups, clearly articulating
who benefited from previous programmes and who did not.
•• Consider failures as well as successes.
73
1.
7.2 Learn, innovate and implement changes on the basis of monitoring and
evaluation, and feedback and complaints.
•• Use open-ended listening and other qualitative participatory approaches.
People affected by crisis are the best sources of information about needs
and changes in the situation.
•• Share and discuss learning with communities, asking them what they would
like to do differently and how to strengthen their role in decision-making or
management.
1.
7.3 Share learning and innovation internally, with communities and people
affected by crisis, and with other stakeholders.
•• Present the information collected through monitoring and evaluation
in an accessible format that allows sharing and decision-making ⊕ see
Commitment 4.
•• Identify ways to support system-wide learning activities.
1.
7.4 Evaluation and learning policies are in place, and means are available to
learn from experiences and improve practices.
•• Organisations include a performance review and improvement plan that is
based on measurable, objective indicators in their learning cycle.
•• All staff understand their responsibilities in relation to monitoring the
progress of their work and how learning can contribute to their professional
development.
1.
7.5 Mechanisms exist to record knowledge and experience and make it
accessible throughout the organisation.
•• Organisational learning leads to practical changes (such as improved strate-
gies for carrying out assessments, reorganisation of teams for more cohesive
response, and clearer articulation of decision-making responsibilities).
1.
7.6 The organisation contributes to learning and innovation in humanitarian
response among peers and within the sector.
•• Compile and publish reports on humanitarian responses, including key lessons
learned and recommendations for revised practices during future responses.
Guidance notes
Learning from experience: Different approaches and methods suit different
performance, learning and accountability purposes:
Monitoring – collection of regular data sets of project activities and performance
can be used for course correction. Use qualitative and quantitative data to monitor
74
and evaluate; triangulate data and maintain consistent records. Consider the ethics
of how data is collected, managed and reported. Determine what data is collected
and how it is presented based on the intended use and users of the data. Do not
collect data that will not be analysed or used.
Real-time reviews – one-off assessment exercises, involving people working on
the project, can be used for course correction.
Feedback – information received from affected people, not necessarily structures,
can be used for course correction. People affected by crisis are the best judges of
changes in their lives.
After-action reviews – one-off exercises, involving people working on project,
occurring after project completion. Identifies elements to retain and change in
future projects.
Evaluations – formal activities to objectively determine the value of an activity,
project or programme, normally conducted by people external to the project, can
be real time (to allow for course correction) or occur after project completion, to
provide learning for similar situations and to inform policy.
Research – this involves systematic investigation into specific defined questions
related to humanitarian action, generally used to inform policy.
Innovation: Crisis response often leads to innovation as people and organisa-
tions adapt to changing environments. People affected by crisis are innovating
as they adapt to their own changing circumstances; they may benefit from
support that involves them more systematically in innovation and develop-
ment processes.
Collaboration and sharing of lessons: Collaborative learning with other agencies,
governmental and non-governmental bodies and academic bodies is a professional
obligation and can introduce fresh perspectives and ideas, as well as maximise the
use of limited resources. Collaboration also helps to reduce the burden of repeated
evaluations in the same community.
Peer-learning exercises have been used by a variety of organisations and
can be undertaken to monitor progress in real time or as a reflective exercise
post-crisis.
Networks and communities of practice (including academia) can create oppor-
tunities to learn from peer groups, both in the field and in after-action reviews
or learning forums. This can make an important contribution to organisational
practice and system-wide learning. Sharing challenges as well as successes
among peers can enable humanitarians to identify risks and avoid future
mistakes.
Evidence that is available across sectors is particularly useful. Learning and
reviewing evidence among organisations is more likely to contribute to organ
isational change than lessons learned within a single organisation.
75
Monitoring performed by the people affected by crisis themselves can enhance

transparency and quality and encourage ownership of the information.
Evaluation and learning policies: Key lessons and areas identified for improvement
are not always addressed systematically, and lessons cannot be considered learned
unless they have brought about demonstrable changes in current or subsequent
responses.
Knowledge management and organisational learning: Knowledge management
involves collecting, developing, sharing, storing and effectively using organ
isational knowledge and learning. Longer-term national staff are often key to
preserving local knowledge and relationships. Learning should also extend to
national, regional and local actors and help them develop or update their own
crisis-preparedness plans.
Commitment 8
Communities and people affected by crisis receive the assistance they
require from competent and well-managed staff and volunteers.
Quality criterion
Staff are supported to do their job effectively and are treated fairly and equitably.
1. All staff feel supported by their organisation to do their work.
2. Staff satisfactorily meet their performance objectives.
3. Communities and people affected by crisis assess staff to be effective in
terms of their knowledge, skills, behaviours and attitudes.
4. Communities and people affected by crisis are aware of humanitarian codes
of conduct and how to raise concerns about violations.
Key actions
1.
8.1 Staff work according to the mandate and values of the organisation and to
agreed objectives and performance standards.
•• Different terms and conditions may apply to staff of different types or levels.
National employment law often dictates the status of an individual and
must be respected. All staff members must be made aware of their legal and
organisational status, whether national or international.
1.
8.2 Staff adhere to the policies that are relevant to them and understand the
consequences of not adhering to them.
•• The need for induction and training on organisational mandate, policies and
codes of conduct applies in all situations, including a rapid deployment or
scale-up.
76
1.
8.3 Staff develop and use the necessary personal, technical and management
competencies to fulfil their role and understand how the organisation can
support them to do this.
•• Opportunities for formal staff development may be limited in the first phase
of response, but managers should provide an induction and on-the-job
training as a minimum.
1.
8.4 The organisation has the management and staff capacity and capability to
deliver its programmes.
•• Hire people who will increase the accessibility of services and avoid any
perception of discrimination, considering language, ethnicity, gender,
disability and age.
•• Consider how the organisation will address peaks in demand for qualified
staff in advance. Clarify country-level roles and responsibilities as well as
internal decision-making responsibilities and communication.
•• Avoid deploying staff for short periods of time which leads to high staff
turnover, undermines continuity and programme quality and may lead to
staff avoiding personal responsibility for assignments.
•• Adopt ethical recruitment practices to avoid the risk of undermining local
NGO capacity.
•• Develop locally recruited staff who are likely to stay for longer periods of
time. In multi-mandated agencies, development staff should be trained and
available for humanitarian response.
1.
8.5 Staff policies and procedures are fair, transparent, non-discriminatory and
compliant with local employment law.
•• Organisational policy and practice promotes the role of national staff at
management and leadership level to ensure continuity, institutional memory
and more contextually appropriate responses.
1.
8.6 Job descriptions, work objectives and feedback processes are in place so
that staff have a clear understanding of what is required of them.
•• Job descriptions are accurate and kept up to date.
•• Staff develop individual objectives for work aspirations and competencies
which are documented in a development plan.
1.
8.7 A code of conduct is in place that establishes, at a minimum, the obligation
of staff not to exploit, abuse or otherwise discriminate against people.
•• The organisation’s code of conduct is understood, signed and upheld,
making it clear to all representatives of the organisation (including staff,
volunteers, partners and contractors) what standards of behaviour are
expected and what the consequences will be if they breach the code.
77
1.
8.8 Policies are in place to support staff to improve their skills and competencies.
•• Organisations should have mechanisms to review staff performance, assess

capacity gaps and develop talent.
1.
8.9 Policies are in place for the security and the well-being of staff.
•• Agencies exercise a duty of care to their workers. Managers make

humanitarian workers aware of risks and protect them from exposure to
unnecessary threats to their physical and emotional health.
•• Measures that can be adopted include effective security management,
preventative health advice, active support for working reasonable hours and
access to psychological support.
•• Establish a policy that expresses zero tolerance for harassment and abuse,
including sexual harassment and abuse, in the workplace.
•• Establish holistic prevention and response strategies to address
incidents of sexual harassment and violence as experienced or
perpetrated by their staff.
Guidance notes
Staff and volunteers: Any designated representative of the organisation, including
national, international, permanent or short-term employees, as well as volunteers
and consultants, is considered to be a member of staff.
Organisations should sensitise staff and volunteers to raise awareness of
marginalised groups and avoid stigmatising and discriminatory attitudes and
practices.
Adhering to organisational mandates, values and policies: Staff are expected to
work within the legal scope, mission, values and vision of the organisation, which
should be defined and communicated to them. Beyond this wider understanding
of the role and ways of working of the organisation, an individual should work
to a set of personal objectives and the performance expectations agreed with
their manager.
Policies should make explicit commitments to gender balance with staff and
volunteers.
Policies should promote a work environment that is open, inclusive and access
ible to persons with disabilities. This might include: identifying and eliminating
barriers to accessibility in the workplace; prohibiting discrimination on the basis
of disability; promoting equal opportunities and equal remuneration for work
of equal value; and providing reasonable adjustments for persons with disabilities
in the workplace.
External partners, contractors and services providers should also know the
policies and codes of conduct that apply to them, as well as the consequences
of non-compliance (such as termination of contracts).
78
Performance standards and development of competencies: Staff and their employ-

ers are mutually accountable for their skills development – including management
skills. With the help of clear objectives and performance standards, they should
understand what skills, competencies and knowledge are required to perform their
current role. They should also be made aware of the opportunities for growth and
development that might be available or required. Competencies can be improved
through experience, training, mentoring or coaching.
There are various methods that can be used to assess a staff member’s skills
and behaviours, including observation, reviewing work output, direct discus-
sions with them and interviewing their colleagues. Regular documented
performance appraisals should allow managers to identify areas for support
and training.
Staff capacity and capability: Personnel management systems differ by agency
and context but should be informed by good practice. They need to be consid-
ered and planned at a strategic level with the support of senior manage-
ment. Organisation and project plans must consider staff capacity and gender
balance. There must be the right number of staff with the right skills in the
right place at the right time to deliver short- and long-term organisational
objectives.
Organisations should ensure that staff have the competencies needed to support
community listening, decision-making and action. Staff should also be trained in
how to apply standard operating procedures, as this allows for higher levels of
delegation and faster responses.
Performance review schedules must be flexible enough to cover staff who work
short-term, as well as those on open-ended contracts. Adequate attention should
be given to competencies of listening, enabling inclusion, facilitating community
dialogue and enabling community decision-making and initiatives. Partner organ-
isations should agree on the competencies required for staff to meet the agreed
commitments.
Staff policies and procedures: The style and complexity of staff policies and
procedures will depend on the size and context of each agency. However simple
or complex the agency may be, staff should participate in the development and
review of policies where possible to ensure that their views are represented.
A staff manual facilitates knowledge of and consultation on policies and the
consequences of non-adherence.
Staff guidance: Each staff member should identify individual objectives that
cover their work aspirations and the competencies they hope to develop, and
document these in a development plan.
An effective response is not simply about ensuring that skilled staff are present,
but also depends on the way that individuals are managed. Research from emer-
gency contexts shows that effective management, frameworks and procedures
79
are as important, if not more important than, the skills of personnel in ensuring an
effective response.
Security and well-being: Staff often work long hours in risky and stressful
conditions. An agency’s duty of care to its national and international staff
includes actions to promote mental and physical well-being and avoid long-
term exhaustion, burnout, injury or illness.
Managers can promote a duty of care through modelling good practice and person-
ally complying with policy. Humanitarian workers also need to take personal
responsibility for managing their well-being. Psychological first aid should be
immediately available to workers who have experienced or witnessed extremely
distressing events.
Train staff to receive information on incidents of sexual violence experienced
by their colleagues. Provide access to robust investigative and deterrence meas-
ures that promote trust and accountability. When incidents do occur, adopt a
survivor-centred approach to medical and psychosocial support, which includes
recognition of vicarious trauma. Support should be responsive to and inclusive of
the needs of expatriate and national staff.
A culturally and linguistically appropriate mental health professional should
contact all national and international staff and volunteers one to three months
after they have survived a potentially traumatic event. The professional should
assess the survivor and refer them for clinical treatment if appropriate.
Commitment 9
Communities and people affected by crisis can expect that the organisations
assisting them are managing resources effectively, efficiently and ethically.
Quality criterion
Resources are managed and used responsibly for their intended purpose.
1. Communities and people affected by crisis are aware of community-level
budgets, expenditures and results achieved.
2. Communities and people affected by crisis consider that the available
resources are being used:
a. for what they were intended; and
b. without diversion or wastage.
3. The resources obtained for the response are used and monitored according
to agreed plans, targets, budgets and time frames.
4. Humanitarian response is delivered in a way that is cost-effective.
80
Key actions
1.
9.1 Design programmes and implement processes to ensure the efficient
use of resources, balancing quality, cost and timeliness at each phase of
the response.
•• Adapt procedures in rapid-onset crises to enable faster financial decision-
making and cope with challenges (for example, a lack of available suppliers to
carry out competitive tenders).
1.
9.2 Manage and use resources to achieve their intended purpose, minimising
waste.
•• Ensure staff with specific skills and systems are in place to manage risks
related to procurement, cash-based assistance and stock management.
1.
9.3 Monitor and report expenditure against budget.
•• Establish financial planning and monitoring systems to ensure that

programme objectives are met, including procedures to mitigate key financial
management risks.
•• Track all financial transactions.
1.
9.4 When using local and natural resources, consider their impact on the
environment.
•• Conduct a rapid environmental impact assessment to determine risk and
put mitigating measures in place as early as possible in the response or
programme.
1.
9.5 Manage the risk of corruption and take appropriate action if it is identified.
•• Document funding criteria and sources of funding. Be open and transparent

with project information.
•• Encourage stakeholders to report abuses of power.
1.
9.6 Policies and processes governing the use and management of resources are
in place, including how the organisation:
a. accepts and allocates funds and gifts-in-kind ethically and legally;
b. uses its resources in an environmentally responsible way;
c. prevents and addresses corruption, fraud, conflicts of interest and
misuse of resources;
d. conducts audits, verifies compliance and reports transparently;
e. assesses, manages and mitigates risk on an ongoing basis; and
f. ensures that the acceptance of resources does not compromise its
independence.
81
Guidance notes
Efficient use of resources: The term “resources” refers to the inputs an organisation
needs to deliver its mission. This includes but is not limited to funds, staff, goods,
equipment, time, land and the environment in general.
In high-profile acute crises, there is often pressure to respond quickly and to
demonstrate that agencies are doing something to address the situation. This
can lead to poor project planning and insufficient emphasis on exploring different
potential programme and financial options (for example, the use of cash-based
assistance) that may offer better value for money. However, the elevated risk of
corruption in these contexts means it is important to provide training and support
to staff and establish complaints mechanisms to prevent corruption within the
systems ⊕ see Commitments 3 and 5.
Deploying experienced senior staff during this time can help to mitigate the risks
and strike a balance between providing a timely response, maintaining standards
and limiting waste.
Collaboration and coordination between organisations (and communities)
can also contribute to a more efficient response (for example, by conducting
joint assessments or evaluations and supporting interagency registration and
logistics systems).
At the end of the project, the assets and resources that remain will need to be
donated, sold or returned responsibly.
Using resources for their intended purpose: All humanitarian actors are accountable
to both donors and affected people and should be able to demonstrate that
resources have been used wisely, efficiently and to good effect.
Accounting records should satisfy accepted national and/or international standards
and should be applied systematically within the organisation.
Fraud, corruption and waste divert resources away from those who need them
most. However, an intervention that is not effective because it is understaffed or
under-resourced cannot be said to be accountable. Economical does not always
equal value for money. A balance will often need to be struck between economy,
effectiveness and efficiency.
Monitoring and reporting on expenditure: All staff members share responsibility
for ensuring that finances are well managed. Staff are encouraged to report any
suspected fraud, corruption or misuse of resources.
Environmental impact and use of natural resources: Humanitarian responses
can have negative impacts on the environment. For example, they can produce
large amounts of waste, degrade natural resources, contribute to the depletion
or contamination of the water table and cause deforestation and other envi-
ronmental hazards. Ecosystems are essential to human well-being and buffer
82
against natural hazards. Any impact on the environment must be addressed as

a cross-sectoral issue, as this may cause further and lasting damage to lives,
health and livelihoods. Involving affected people and their concerns in this process
is key. Support for the local management of natural resources should be integrated
into programming.
Managing corruption risks: The definition and understanding of corrupt practices
is not the same in all cultures. A clear definition of the behaviour that is expected
of staff (including volunteers) and partners is fundamental in addressing this risk
⊕ see Commitment 8. Engaging respectfully with community members, and
establishing on-site monitoring mechanisms and transparency with stake-
holders can help to reduce corruption risks.
Gifts-in-kind may create ethical dilemmas. Giving gifts in many cultures is
an important social norm, and refusing a gift would appear rude. If receiving
the gift causes a sense of indebtedness, the receiver should politely refuse it.
If it is accepted, it is important to declare this and discuss it with a manager if
concerns remain. Mitigate risks for operational independence and organisational
impartiality by producing guidance for staff and encouraging transparency. Staff
should be made aware of such policies and possible dilemmas.
Natural resources and environmental impact: Organisations should commit to
environmentally sound policies and practices (including a plan of action and
rapid environmental impact assessment) and make use of existing guidelines to
help address environmental issues in an emergency. Green procurement policies
help reduce the impact on the environment but need to be managed in a way
that minimises delay in the provision of assistance.
Corruption and fraud: Fraud includes theft, diversion of goods or property and
the falsification of records such as expense claims. Every organisation must keep
an accurate record of financial transactions to show how funds have been used.
Establish systems and procedures to ensure internal control of financial resources
and to prevent fraud and corruption.
Organisations should support recognised good practice in financial manage-
ment and reporting. Organisational policies should also ensure that procure-
ment systems are transparent and robust and incorporate counter-terrorism
measures.
Conflicts of interest: Staff must ensure that there is no conflict between the aims
of the organisation and their own personal or financial interests. For example, they
must not award contracts to suppliers, organisations or individuals if they or their
family stand to gain financially.
There are various forms of conflict of interest, and people do not always recognise
that they are contravening organisational codes and policies. For example, using
the organisation’s resources without permission or taking gifts from a supplier
might be construed as a conflict of interest.
83
Creating a culture where people feel that they can openly discuss and declare any
potential or actual conflicts of interest is key to managing them.
Auditing and transparency: Audits can take several forms. Internal audits check
that procedures are being followed. External audits verify whether the organ
isation’s financial statements are true and fair. An investigative audit is executed
when an organisation suspects a specific problem, usually fraud.
84
Appendix – Guiding questions for monitoring Key actions and Organisational responsibilities
Appendix
Guiding questions for monitoring
key actions and organisational responsibilities
Below are some guiding questions related to the Core Humanitarian Standard’s
key actions and organisational responsibilities. These questions can be used
to support programme design or as a tool for reviewing a project, response
or policy.
Commitment 1 Communities and people affected by crisis receive assistance

appropriate to their needs.
Guiding questions for monitoring key actions

1. Has a comprehensive and consultative assessment of capacities and needs
been conducted and used to inform response planning?
2. Are affected people and communities, local institutions and other stake-
holders (including representative groups for women, men, girls and boys)
consulted when assessing needs, risks, capacities, vulnerabilities and
context? Are assessment and monitoring data disaggregated by sex, age
and disability?
3. How have at-risk groups been identified?
4. Are relevant cross-cutting issues considered in the needs and context analysis?
5. Does the response provide assistance in a way that is adapted to the
needs and preferences of the affected population (for example, in-kind,
cash)? Are there different types of assistance and protection for different
demographic groups?
6. What actions are taken to adapt the response strategy to different
demographic groups, based on changing needs, capacities, risks and
the context?
Guiding questions for monitoring organisational responsibilities

1. Does the organisation have a clear policy commitment to rights-based, impartial
and independent humanitarian action, and are staff members aware of it?
2. Do relevant stakeholders perceive the organisation as impartial, independent
and non-discriminatory?
3. Do working processes include mechanisms for consistently collecting
data disaggregated by sex, age, disability and other relevant
characteristics?
4. Is this data regularly used to guide programme design and implementation?
A1
5. Does the organisation have the funding, staffing policies and programmatic
flexibility to allow it to adapt the response to changing needs?
6. Does the organisation systematically carry out market analysis to determine
the appropriate forms of assistance?
Commitment 2 Communities and people affected by crisis have access to the

humanitarian assistance they need at the right time.
Guiding questions for monitoring Key actions

1. Are constraints such as physical barriers or discrimination and risks regularly
identified and analysed, and plans adapted accordingly together with the
affected population?
2. Does planning consider optimal times for activities, accounting for factors
such as weather, season, social factors, ease of access or conflict?
3. Are delays in implementing plans and activities monitored and addressed?
4. Are early warning systems and contingency plans used?
5. Are recognised technical standards used and achieved?
6. Are unmet needs identified and addressed?
7. Are the results of monitoring used to adapt programmes?

1. Are there clear processes to assess whether the organisation has sufficient
ability, financing and appropriate deployable staff available before making
programming commitments?
2. Are there clear policies, processes and resources in place to support
monitoring and evaluation and to use the results for management and
decision-making? Are they known to staff?
3. Are there clear processes to define responsibilities and timelines for
decision-making on resource allocations?
Commitment 3 Communities and people affected by crisis are not negatively

affected and are more prepared, resilient and less at-risk as a result of
humanitarian action.

1. Have local capacities for resilience (structures, organisations, informal
groups, leadership figures and support networks) been identified and do
plans exist to strengthen these capacities?
2. Is existing information on risks, hazards, vulnerabilities and related plans
used in programming activities?
3. Has the programme considered whether and how services could be
provided by local civil society, government or private sector bodies? Are
plans in place to support these bodies as they take over the provision of
relevant services?
A2
4. Are strategies and actions to reduce risk and build resilience designed in
consultation with, or guided by, affected people and communities?
5. In what ways (both formal and informal) are local leaders and/or authorities
consulted to ensure response strategies are in line with local and/or national
priorities?
6. Are staff sufficiently supportive of local initiatives, including community-based
self-help initiatives, particularly for marginalised and minority groups, first
response and building capacities for future response?
7. Is the response designed to facilitate early recovery?
8. Is there progressive ownership and decision-making by local people?
9. Has a market assessment been completed, to identify possible impacts of
the programme on the local economy?
10. Has a clear transition and/or exit strategy been developed in consultation
with affected people and other relevant stakeholders?

1. Is there a policy that requires the execution of risk assessments and
risk-reduction exercises for vulnerable people in the organisation’s
programme areas? Is it known to staff?
2. Do policies and procedures exist for assessing and mitigating the negative
effects of the response? Are they known to staff?
3. Are policies and procedures in place to deal with situations of sexual
exploitation, abuse or discrimination, including based on sexual orientation
or other characteristics? Are they known to staff?
4. Are contingency plans in place for responding to new or evolving crises?
Are they known to staff?
5. Do staff understand what is expected of them on issues of protection,
security and risks?
6. Does the organisation enable and promote community-led action and
self-help?
Commitment 4 Communities and people affected by crisis know their rights

and entitlements, have access to information and participate in decisions that
affect them.

1. Is information about the organisation and response provided in accessible
and appropriate ways to different affected groups?
2. Can women, men, girls and boys (especially those who are marginalised
and vulnerable) access the information provided, and do they under-
stand it?
3. Are affected people’s views, including those of the most vulnerable
and marginalised, sought and used to guide programme design and
implementation?
A3
4. Are all groups within the affected community aware of how to give
feedback on the humanitarian response, and do they feel safe using
those channels?
5. Is feedback used? Can the programme point to elements that have been
changed based on feedback? ⊕ See Key actions 1.3 and 2.5.
6. Are barriers to giving feedback identified and addressed?
7. Is data that is provided through feedback mechanisms disaggregated by sex,
age, disability and other relevant categories?
8. Where assistance is provided through electronic transfers, are feedback
channels available to people, even where there is no direct contact
with staff?

1. Do policies and programme plans include provisions for information-sharing,
including criteria on what information should and should not be shared?
Are they known to staff?
2. Do policies and programme plans include provisions for data protection?
Are there criteria for safe data storage (in lockable cabinets for hard copies,
and password protected files for soft copies), restricted access, destruction
of data in case of evacuation and information sharing protocols? Do such
protocols detail what information should be shared, with whom and in which
situations? Keep in mind that information should only be shared on a strictly
need-to-know basis and should not contain identifying details or case
histories unless necessary.
3. Do policies include provisions on how to deal with confidential or sensitive
information, or information that could potentially place staff or affected
people at risk? Are they known to staff?
4. Are there policy commitments and guidelines about the way in which
affected people are represented in external communications or fundraising
materials? Are they known to staff?
Commitment 5 Communities and people affected by crisis have access to safe

and responsive mechanisms to handle complaints.

1. Are communities and people affected by crisis consulted about the design of
complaints mechanisms?
2. Are the preferences of all demographic groups considered, particularly those
related to safety and confidentiality, in the design of complaints-handling
processes?
3. Is information provided to and understood by all demographic groups about
how complaint mechanisms work and what kinds of complaints can be made
through them?
A4
4. Are there agreed and respected time frames for investigating and resolving
complaints? Is the time between when a complaint is filed and its resolution
recorded?
5. Are complaints about sexual exploitation, abuse and discrimination investi-
gated immediately by staff with relevant competencies and an appropriate
level of authority?

1. Are specific policies, budgets and procedures in place for handling complaints?
2. Are all staff provided with induction and refresher training on the organ
isation’s policy and procedures for handling complaints?
3. Does the organisation’s complaints-handling policy include provisions for
sexual exploitation, abuse and discrimination?
4. Is the organisation’s policy commitment and procedures for preventing
sexual exploitation, abuse and discrimination shared with affected
people?
5. Are complaints that cannot be addressed by the organisation referred in a
timely manner to other relevant organisations?
Commitment 6 Communities and people affected by crisis receive coordinated,

complementary assistance.

1. Is information about the organisation’s competencies, resources, and
geographical areas and sectors of work shared in a timely way with others
responding to the crisis?
2. Is information about the competencies, resources, and geographical
coverage and sectors of work of other organisations, including local and
national authorities, accessed and used?
3. Have existing coordination structures been identified and supported?
4. Are the programmes of other organisations and authorities considered when
designing, planning and implementing programmes?
5. Are gaps and duplication in coverage identified and addressed?

1. Is there a clear commitment in organisational policies and/or strategies to
work in collaboration with other actors?
2. Have criteria or conditions for partner selection, collaboration and coordin
ation been established?
3. Are formal partnership arrangements in place?
4. Do partnership agreements include clear definitions of the roles,
responsibilities and commitments of each partner, including how each
partner will contribute to jointly meeting humanitarian principles?
A5
Commitment 7 Communities and people affected by crisis can expect

delivery of improved assistance as organisations learn from experience
and reflection.

1. Are evaluations and reviews of responses of similar crises consulted and
incorporated, as relevant, in programme design?
2. Are monitoring, evaluation, feedback and complaints-handling processes
leading to changes and/or innovations in programme design and
implementation?
3. Is learning systematically documented?
4. Are specific systems used to share learning with relevant stakeholders,
including affected people and partners?

1. Do policies and resources exist for evaluation and learning? Are they known
to staff?
2. Does clear guidance exist for the recording and dissemination of learning,
including specific guidance applicable to humanitarian crises?
3. Is learning identified at programme level, documented and shared within the
organisation?
4. Is the organisation an active member of learning and innovation forums?
How does the organisation contribute to these forums?
Commitment 8 Communities and people affected by crisis receive the assistance

they require from competent and well-managed staff and volunteers.

1. Are the organisation’s mandate and values communicated to new staff?
2. Is staff performance managed, under-performance addressed and good
performance recognised?
3. Do staff sign a code of conduct or similarly binding document? If so, is their
understanding of the policy supported by training on it and on other relevant
policies?
4. Are complaints received about staff or partners’ staff? How are they
handled?
5. Are staff aware of support available for developing the competencies
required by their role, and are they making use of it?

1. Are procedures in place for assessing human resource needs in relation to
programme size and scope?
2. Does organisational planning make provision for future leadership needs and
for developing new talent?
A6
3. Do staff policies and procedures comply with local employment law and
follow recognised good practice in managing staff?
4. Do staff security and well-being policies cover the practical and psycho-
social needs of local staff who may have been personally affected by
the crisis?
5. Are soft skills that support the ability of staff to listen to and account for
feedback from people affected by crisis taken into consideration when
recruiting, training and appraising staff?
6. Do all staff have updated job descriptions and objectives, including specific
responsibilities?
7. Is the compensation and benefits structure fair, transparent and consistently
applied?
8. Are all staff inducted and updated on performance management and staff
development policies and procedures?
9. Are all staff (and contractors) required to sign a code of conduct (that covers
the prevention of sexual exploitation and abuse) and provided with an
appropriate induction on the code of conduct?
10. Is there a clear statement/clause/code of conduct included in the contract
with financial service providers and commercial actors to prevent sexual and
other exploitation?
11. Does the organisation have location-specific guidelines for an internal
complaints-handling mechanism? Are these known to staff?
12. Do staff members understand, recognise and respond to discrimination in
their own programmes and activities?
Commitment 9 Communities and people affected by crisis can expect that the
organisations assisting them are managing resources effectively, efficiently
and ethically.

1. Are staff following organisational protocols for decisions regarding
expenditure?
2. Is expenditure monitored regularly and are the reports shared across
programme management?
3. Are services and goods procured using a competitive bidding process?
4. Are potential impacts on the environment (water, soil, air, biodiversity)
monitored and actions taken to mitigate them?
5. Is a safe whistleblowing procedure in place and known to staff, affected
people and other stakeholders?
6. Are cost-effectiveness and social impact monitored?

1. Do policies and procedures exist for ethical procurement, use and manage-
ment of resources?
A7
2. Do these include provisions for:

•• acceptance and allocation of funds?
•• acceptance and allocation of gifts-in-kind?
•• mitigation and prevention of environmental impacts?
•• fraud prevention, handling of suspected and proven corruption and
misuse of resources?
•• conflicts of interest?
•• auditing, verification and reporting?
•• asset risk assessment and management?
A8

Additional resources for the Core Humanitarian Standard:
corehumanitarianstandard.org
CHS Alliance: www.chsalliance.org
CHS Quality Compass: www.urd.org
Overseas Development Institute (ODI): www.odi.org
Accountability
Child Protection Minimum Standards (CPMS). Global Child Protection Working Group,
2010. http://cpwg.net
Complaints Mechanism Handbook. ALNAP, Danish Refugee Council, 2008.
www.alnap.org
Guidelines on Setting Up a Community Based Complaints Mechanism Regarding
SexualExploitation and Abuse by UN and non-UN Personnel. PSEA Task Force, IASC
Taskforce, 2009. www.pseataskforce.org
Humanitarian inclusion standards for older people and people with disabilities. Age and
Disability Consortium, 2018. www.refworld.org
Lewis, T. Financial Management Essentials: Handbook for NGOs. Mango, 2015.
www.mango.org
Livestock Emergency Guidelines and Standards (LEGS). LEGS Project, 2014.
https://www.livestock-emergency.net
Minimum Economic Recovery Standards (MERS). SEEP Network, 2017.
https://seepnetwork.org
Minimum Standards for Education: Preparedness, Recovery and Response. The Inter-
Agency Network for Education in Emergencies INEE, 2010. www.ineesite.org
Munyas Ghadially, B. Putting Accountability into Practice. Resource Centre, Save
the Children, 2013. http://resourcecentre.savethechildren.se
Top Tips for Financial Governance. Mango, 2013. www.mango.org
Aid worker performance

A Handbook for Measuring HR Effectiveness. CHS Alliance, 2015.
http://chsalliance.org
Building Trust in Diverse Teams: The Toolkit for Emergency Response. ALNAP, 2007.
www.alnap.org
Protection Against Sexual Exploitation and Abuse (PSEA). OCHA.
https://www.unocha.org
85
Protection from Sexual Exploitation and Abuse. CHS Alliance.

https://www.chsalliance.org
Rutter, L. Core Humanitarian Competencies Guide: Humanitarian Capacity Building
Throughout the Employee Life Cycle. NGO Coordination Resource Centre, CBHA, 2011.
https://ngocoordination.org
World Health Organization, War Trauma Foundation and World Vision International.
Psychological First Aid: Guide for Field Workers. WHO Geneva, 2011.www.who.int
Assessments
Humanitarian Needs Assessment: The Good Enough Guide. ACAPS and ECB, 2014.
www.acaps.org
Multi-sector Initial Rapid Assessment Manual (revised July 2015). IASC, 2015.
https://interagencystandingcommittee.org
Participatory assessment, in Participation Handbook for Humanitarian Field Workers
(Chapter 7). ALNAP and Groupe URD, 2009. http://urd.org
Cash-based response
Blake, M. Propson, D. Monteverde, C. Principles on Public-Private Cooperation in
Humanitarian Payments. CaLP, World Economic Forum, 2017.
www.cashlearning.org
Cash or in-kind? Why not both? Response Analysis Lessons from Multimodal
Programming. Cash Learning Partnership, July 2017. www.cashlearning.org
Martin-Simpson, S. Grootenhuis, F. Jordan, S. Monitoring4CTP: Monitoring Guidance
for CTP in Emergencies. Cash Learning Partnership, 2017.
Children
Child Safeguarding Standards and how to implement them. Keeping Children Safe,
2014. www.keepingchildrensafe.org
Coordination
Knox Clarke, P. Campbell, L. Exploring Coordination in Humanitarian Clusters.
ALNAP, 2015. https://reliefweb.int
Reference Module for Cluster Coordination at the Country Level. Humanitarian
Response, IASC, 2015. www.humanitarianresponse.info
Design and response

The IASC Humanitarian Programme Cycle. Humanitarian Response.
www.humanitarianresponse.info
Persons with Disability

Convention on the Rights of Persons with Disabilities. United Nations.
https://www.un.org
86
Washington Group on Disability Statistics and sets of disability questions. Washington

Group. www.washingtongroup-disability.com
Environment
Environment and Humanitarian Action: Increasing Effectiveness, Sustainability and
Accountability. UN OCHA/UNEP, 2014. www.unocha.org
The Environmental Emergencies Guidelines, 2nd edition. Environment Emergencies
Centre, 2017. www.eecentre.org
Training toolkit: Integrating the environment into humanitarian action and early recovery.
UNEP, Groupe URD. http://postconflict.unep.ch
Gender
Mazurana, D. Benelli, P. Gupta, H. Walker, P. Sex and Age Matter: Improving
Humanitarian Response in Emergencies. ALNAP, 2011, Feinstein International Center,
Tufts University.
Women, Girls, Boys and Men: Different Needs, Equal Opportunities, A Gender Handbook
for Humanitarian Action. IASC, 2006. https://interagencystandingcommittee.org
Guidelines for Integrating Gender-based Violence Interventions in Humanitarian Action:
Reducing risk, promoting resilience, and aiding recovery. GBV Guidelines, IASC, 2015.
http://gbvguidelines.org
Handbook for Coordinating Gender-based Violence Interventions in Humanitarian
Settings. United Nations, UNICEF, November 2010. https://www.un.org
People-centred humanitarian response

Bonino, F. Jean, I. Knox Clarke, P. Closing the Loop – Effective Feedback in
Humanitarian Contexts. ALNAP, March 2014, London. www.alnap.org
Participation Handbook for Humanitarian Field Workers. Groupe URD, ALNAP, 2009.
www.alnap.org
What is VCA? An Introduction to Vulnerability and Capacity Assessment. IFRC, 2006,
Geneva. www.ifrc.org
Performance, monitoring and evaluation

Catley, A. Burns, J. Abebe, D. Suji, O. Participatory Impact Assessment: A Design Guide.
Tufts University, March 2014, Feinstein International Center, Somerville.
http://fic.tufts.edu
CHS Alliance and Start, A. Building an Organisational Learning & Development
Framework: A Guide for NGOs. CHS Alliance, 2017. www.chsalliance.org
Hallam, A. Bonino, F. Using Evaluation for a Change: Insights from Humanitarian
Practitioners. ALNAP Study, October 2013, London. www.alnap.org
Project/Programme Monitoring and Evaluation (M&E) Guide. ALNAP, IRCS, January
2011. https://www.alnap.org
87
Sphere for Monitoring and Evaluation. The Sphere Project, March 2015.
www.sphereproject.org
Protection
Slim, H. Bonwick, A. Protection: An ALNAP Guide for Humanitarian Agencies. ALNAP,
2005. www.alnap.org
Recovery
Minimum Economic Recovery Standards. SEEP Network, 2017.
Resilience
Reaching Resilience: Handbook Resilience 2.0 for Aid Practitioners and Policymakers
in Disaster Risk Reduction, Climate Change Adaptation and Poverty Reduction. Reaching
Resilience, 2013. www.reachingresilience.org
Turnbull, M. Sterret, C. Hilleboe, A. Toward Resilience, A Guide to Disaster Risk Reduction
and Climate Change Adaptation. Catholic Relief Services, 2013. www.crs.org
Further reading
For further reading suggestions please go to www.spherestandards.org/handbook/
online-resources
88
Further reading
Further reading
Accountability
Hees, R. Ahlendorf, M. Debere, S. Handbook of Good Practices: Preventing Corruption in
Humanitarian Operations. Transparency International, 2010. www.transparency.org/
whatwedo/publication/handbook_of_good_practices_preventing_corruption_
in_humanitarian_operations
Value for Money: What it Means for UK NGOs (background paper). Bond, 2012.
www.bond.org.uk/data/files/Value_for_money_-_what_it_means_for_NGOs_
Jan_2012.pdf
Aid worker performance

Centre of Excellence – Duty of Care: An Executive Summary of the Project Report. CHS
Alliance, 2016. https://www.chsalliance.org/files/files/Resources/Articles-and-
Research/Duty%20of%20Care%20-%20Summary%20Report%20April%202017.pdf
CHS Alliance and Start, A. HR Metrics Dashboard: A Toolkit. CHS Alliance, 2016. www.
chsalliance.org/files/files/Resources/Tools-and-guidance/CHS-Alliance-HR-
metrics-dashboard-toolkit.pdf
CHS Alliance and Lacroix, E. Human Resources Toolkit for Small and Medium Nonprofit
Actors. CHS Alliance, 2017. www.chsalliance.org/files/files/Resources/Tools-and-
guidance/HR%20Toolkit%20-%202017.pdf
Debriefing: Building Staff Capacity. CHS Alliance, People In Aid, 2011. http://
chsalliance.org/files/files/Resources/Case-Studies/Debriefing-building-
staff-capacity.pdf
Nightingale, K. Building the Future of Humanitarian Aid: Local Capacity and
Partnerships in Emergency Assistance. Christian Aid, 2012. www.christianaid.
org.uk/resources/about-us/building-future-humanitarian-aid-local-capacity-
and-partnerships-emergency
PSEA Implementation Quick Reference Handbook. CHS Alliance, 2017. www.chsalliance.
org/what-we-do/psea/psea-handbook
Design and response

Camp Management Toolkit. Norwegian Refugee Council, 2015. http://cmtoolkit.org/
IASC Reference Module for the Implementation of The Humanitarian Programme
Cycle (Version 2.0). IASC, 2015. https://interagencystandingcommittee.org/iasc-
transformative-agenda/documents-public/iasc-reference-module-implementation-
humanitarian
Environment
Environment and Humanitarian Action (factsheet). OCHA and UNEP, 2014. www.
unocha.org/sites/dms/Documents/EHA_factsheet_final.pdf
F1
People-centred humanitarian response

A Red Cross Red Crescent Guide to Community Engagement and Accountability (CEA):
Improving Communication, Engagement and Accountability in All We Do. IFRC, 2016.
http://media.ifrc.org/ifrc/wp-content/uploads/sites/5/2017/01/CEA-GUIDE-
2401-High-Resolution-1.pdf
Communication Toolbox: Practical Guidance for Program Managers to Improve
Communication with Participants and Community Members. Catholic Relief
Services, 2013. www.crs.org/our-work-overseas/research-publications/
communication-toolbox
How to Use Social Media to Better Engage People Affected by Crises. FRC, 2017.
http://media.ifrc.org/ifrc/document/use-social-media-better-engage-people-
affected-crises/
Infosaid Diagnostic Tools. CDAC Network, 2012. www.cdacnetwork.org/tools-and-
resources/i/20140626100739-b0u7q
Infosaid E-learning course. CDAC Network, 2015. www.cdacnetwork.org/learning-
centre/e-learning/
Performance, monitoring and evaluation

Buchanan-Smith, M. Cosgrave, J. Evaluation of Humanitarian Action: Pilot Guide.
ALNAP, 2013. www.alnap.org/help-library/evaluation-of-humanitarian-action-
pilot-guide
Norman, B. Monitoring and Accountability Practices for Remotely Managed Projects
Implemented in Volatile Operating Environments. ALNAP, Tearfund, 2012. www.alnap.
org/resource/7956
F2
Water Supply,
Sanitation
and Hygiene
Promotion
Humanitarian
Charter
Protection Core
Standard
Water Supply, Sanitation, and Hygiene Promotion (WASH)
WASH in
disease
Hygiene Water Excreta Vector Solid waste
outbreaks and
promotion supply management control management
healthcare
settings
Standard 1.1 Standard 2.1 Standard 3.1 Standard 4.1 Standard 5.1 Standard 6
Hygiene Access and Environment Vector control Environment WASH in
promotion water quantity free from at settlement free from solid healthcare
human excreta level waste settings
Standard 1.2 Standard 2.2 Standard 3.2 Standard 4.2 Standard 5.2
Identification, Water quality Access to and Household and Household and
access and use of toilets personal personal
use of hygiene actions to actions to
items control vectors safely manage
solid waste
Standard 1.3 Standard 3.3 Standard 5.3

Menstrual Management Solid waste
hygiene and main management
management tenance systems at
and of excreta community
incontinence collection, level
transport,
disposal
and treatment
APPENDIX 1 Water supply, sanitation and hygiene promotion initial needs assessment checklist
APPENDIX 2 The F diagram: Faecal–oral transmission of diarrhoeal diseases
APPENDIX 3 Minimum water quantities: survival figures and quantifying water needs
APPENDIX 4 Minimum numbers of toilets: community, public places and institutions
APPENDIX 5 Water- and sanitation-related diseases
APPENDIX 6 Household water treatment and storage decision tree
90
Contents
Essential concepts in water supply, sanitation and hygiene promotion...................92
Water supply, sanitation, and hygiene promotion standards:
1. Hygiene promotion....................................................................................................96
2. Water supply............................................................................................................. 105
3. Excreta management............................................................................................. 113
4. Vector control........................................................................................................... 121
5. Solid waste management..................................................................................... 126
6. WASH in disease outbreaks and healthcare settings................................. 131
Appendix 1: Water supply, sanitation and hygiene promotion initial
needs assessment checklist..........................................................................139
Appendix 2: The F diagram: faecal–oral transmission
of diarrhoeal diseases.................................................................................... 144
Appendix 3: Minimum water quantities: survival figures
and quantifying water needs....................................................................... 145
Appendix 4: Minimum numbers of toilets: community, public places
and institutions................................................................................................. 146
Appendix 5: Water- and sanitation-related diseases ................................................. 147
Appendix 6: Household water treatment and storage decision tree...................... 150
References and further reading............................................................................................ 151
91
WATER SUPPLY, SANITATION AND HYGIENE PROMOTION
Essential concepts in water supply,

sanitation and hygiene promotion
Everyone has the right to water and sanitation
The Sphere Minimum Standards for water supply, sanitation and hygiene promo
tion (WASH) are a practical expression of the right to access water and sanitation
in humanitarian contexts. The standards are grounded in the beliefs, principles,
duties and rights declared in the Humanitarian Charter. These include the right
to life with dignity, the right to protection and security, and the right to receive
humanitarian assistance on the basis of need.
For a list of the key legal and policy documents that inform the Humanitarian
Charter ⊕ see Annex 1: Legal foundation to Sphere.
People affected by crises are more susceptible to illness and death from disease,
particularly diarrhoeal and infectious diseases. Such diseases are strongly related
to inadequate sanitation and water supplies and poor hygiene. WASH programmes
aim to reduce public health risks.
The main pathways for pathogens to infect humans are faeces, fluids, fingers, flies
and food. The main objective of WASH programmes in humanitarian response
is to reduce public health risks by creating barriers along those pathways ⊕ see
Appendix 2: The F diagram. The key activities are:
•• promoting good hygiene practices;

•• providing safe drinking water;
•• providing appropriate sanitation facilities;
•• reducing environmental health risks; and
•• ensuring conditions that allow people to live with good health, dignity,
comfort and safety.
In WASH programmes, it is important to:
•• manage the entire water chain: water sourcing, treatment, distribution,

collection, household storage and consumption;
•• manage the entire sanitation chain in an integrated manner;
•• enable positive healthy behaviours; and
•• ensure access to hygiene items.
Community engagement is crucial

Community engagement in WASH is a dynamic process connecting the community
and other stakeholders so that people affected by the crisis have more control over
the response and its impact on them. Effective engagement links communities and
response teams to maximise community influence to reduce public health risks,
92
ESSENTIAL CONCEPTS
provide appropriate, accessible services, improve programme quality and estab

lish accountability. It explores the capacity and willingness of the community to
manage and maintain WASH systems ⊕ see Figure 4 WASH Community Engagement.
Engaging with the community creates an essential understanding of perceptions,
needs, coping mechanisms, capacities, existing norms, leadership structures
and priorities, as well as the appropriate actions to take. Monitoring and evalu
ation, including feedback mechanisms, demonstrate whether WASH responses
are appropriate or need to be adjusted. ⊕ see Core Humanitarian Standard
CONTEXT PEOPLE BEHAVIOUR +

Type/location of crisis; Demography, leadership PRACTICE
response actors & structures, gender & power Before/after crisis; coping
institutions; analysis of dynamics, history, strategies, norms, beliefs,
public health risks; education, religion, rumours; risk prevention
status of WASH ethnicity, influential knowledge compared to
infrastructure; food, individuals/groups practice; access to/use
livelihoods and of services; motivation
protection analysis for change in
behaviour/practice
ADVOCACY
for WASH & other
community priorities INFORMATION +
COMMUNICATION
Practical, appropriate for
COORDINATION +
COMMUNITY context, and delivered
COLLABORATION ENGAGEMENT through diverse channels.
Content on access to
with national, services & reducing risk
international & local
actors to influence
decision-making
CAPACITY BUILDING
with staff, partners, and
MONITORING, communities
EVALUATION PARTICIPATION
+ LEARNING Increase community
Analyse monitoring data, ownership, ACCOUNTABILITY
share with communities decision-making, and Welcome and address
and agree adaptations of control over processes, complaints. Use power
programme where facilities, services responsibly
possible
Analysis
Programme
External engagement
WASH Community Engagement (Figure 4)
WASH requires particular considerations in urban areas

Community engagement can be harder in urban areas, where the population
density is higher and atrisk groups are less visible. However, in urban areas, public
spaces, media and technology can provide the opportunity for broader and more
93
efficient dialogue. Diverse ownership of assets (household in rural areas, public–

private mix in urban areas) affects the choice of response options and methods of
delivery.
A combination of approaches is needed

Market-based assistance can efficiently and effectively meet WASH needs, such
as by ensuring access to hygiene items. Cash-based assistance (direct cash and/or
vouchers) should be complemented by other WASH activities, including technical
assistance and community engagement. For implementation, options vary from
infrastructure construction to hygiene promotion and community mobilisation.
Generators or temporary toilets can be provided immediately, while an overhaul
of water treatment services is a long-term project. Quality control and technical
assistance are critical to ensure health and safety. Technical assistance should
be timely and appropriate. It should be consistent, accessible and achievable to
deliver sustainably.
WASH responses should enhance long-term community goals and minimise
environmental impact. Integrated water and sanitation management should
meet human needs and protect the ecosystem. This can influence the choice of
technology, timing and phasing of activities, community engagement, private
sector and market engagement, and financing options.
These Minimum Standards should not be applied in isolation

The right to adequate water and sanitation is linked to the rights to shelter, food
and health. Effective progress in achieving the Minimum Standards in one area
influences progress in other areas. Close coordination and collaboration with other
sectors as well as coordination with local authorities and other responding agen
cies helps ensure that needs are met, that efforts are not duplicated, and that the
quality of WASH responses is optimised. For example, where nutritional standards
are not met, the urgency to meet the water and sanitation standards is higher
because people’s vulnerability to disease has increased. The same applies to popu
lations where HIV prevalence is high. Cross-references throughout the Handbook
suggest some potential linkages.
Where national standards are lower than the Sphere Minimum Standards,
humanitarian organisations should work with the government to progressively
raise them.
International law specifically protects the right to water and sanitation

The right includes access to a sufficient, safe and affordable water supply for personal
and domestic use, and private, safe and clean sanitation facilities. States are obliged
to ensure this right during crises ⊕ see Annex 1: Legal foundation to Sphere.
Safe water and appropriate sanitation facilities are essential to:
•• sustain life, health and dignity;

•• prevent death from dehydration;
94
ESSENTIAL CONCEPTS
•• reduce the risk of water-, sanitation- and hygiene-related diseases; and

•• allow for adequate consumption, cooking, and personal and domestic
hygienic requirements.
The right to water and sanitation is part of the universal rights essential for human
survival and dignity, and state and non-state actors have responsibilities to fulfil
the right. During armed conflict, for example, attacking, destroying, removing or
making water installations or irrigation works useless is prohibited.
Links to the Protection Principles and the Core Humanitarian Standard
Water use affects protection. Armed conflict and inequity affect water security for
individuals and groups. Multiple demands for water for consumption and domestic
and livelihoods purposes can cause protection concerns if short- and long-term
activities are not designed appropriately. Protection in WASH responses is often
considered from the perspective of personal protection and safety, recognising
particular vulnerability during water collection, defecation or menstrual hygiene
management. Such personal protection elements are essential, but wider protec
tion concerns are fundamental, too. Simple measures from the start, such as locks
on toilet doors, adequate lighting and facilities segregation can reduce the risk of
abuse or violence.
Adapted and inclusive programming is essential to avoid discrimination, reduce
potential risks and improve usage or quality of services. For example, ensure that
persons with disabilities can access hygiene facilities, and that women or children
have appropriately sized containers in which to carry water. Engaging individuals
and communities in all stages of the response can help incorporate protection
considerations into WASH programmes.
Aid workers should be trained on child safeguarding and know how to use refe
rral systems for suspected cases of violence, abuse or exploitation, including
of children.
Civil–military cooperation and coordination should be carefully considered for
humanitarian organisations, particularly in conflicts. Perceptions of neutrality
and impartiality may affect community acceptance. Humanitarian organ
isations may have to accept military help in some situations, for example in
transportation and distribution. However the impact on humanitarian princi
ples must be carefully considered and efforts made to mitigate protection risks
⊕ see Humanitarian Charter, and Settings with domestic and international military
forces in What is Sphere?
In applying the Minimum Standards, all nine Commitments in the Core
Humanitarian Standard should be respected as a foundation for providing an
accountable WASH programme.
95
1. Hygiene promotion
Diseases related to water, sanitation and hygiene cause significant preventa
ble sickness and death in crises. Hygiene promotion that supports behaviours,
community engagement, and actions to reduce the risk of disease is fundamental
to a successful WASH response.
A standardised approach that relies mostly on teaching messages and distributing
hygiene items is unlikely to be very effective. Risks–and the perception of risks–
vary across contexts. People have different life experiences, coping strategies,
and cultural and behavioural norms. It is important to adapt approaches based
on analysis of these factors as well as context. Effective hygiene promotion
relies on:
•• working with the community to mobilise action and contribute to

decision-making;
•• two-way communication and feedback on risks, priorities and services; and
•• access to and use of WASH facilities, services and materials.
Hygiene promotion should build on people’s own knowledge of risk and disease
prevention to promote positive health-seeking behaviour.
Monitor activities and outcomes regularly to ensure that hygiene promotion
and WASH programmes evolve. Coordinate with health actors to monitor
the incidence of WASH-related diseases such as diarrhoeal disease, cholera,
typhoid, trachoma, intestinal worms and schistosomiasis ⊕ see Essential
healthcare – communicable diseases standards 2.1.1 to 2.1.4 and Health systems
standard 1.5.
Hygiene promotion standard 1.1:

Hygiene promotion
People are aware of key public health risks related to water, sanitation and
hygiene, and can adopt individual, household and community measures to
reduce them.
Key actions
1.
1 Identify the main public health risks and the current hygiene practices that
contribute to these risks.
•• Develop a community profile to determine which individuals and groups are
vulnerable to which WASH-related risks and why.
•• Identify factors that can motivate positive behaviours and preventive
action.
96
HYGIENE PROMOTION
2.
2 Work with the affected population to design and manage hygiene promotion
and the wider WASH response.
•• Develop a communications strategy using both mass media and community
dialogue to share practical information.
•• Identify and train influential individuals, community groups and outreach workers.
3.
3 Use community feedback and health surveillance data to adapt and improve
hygiene promotion.
•• Monitor access to and use of WASH facilities, and how hygiene promotion
activities affect behaviour and practice.
•• Adapt activities and identify unmet needs.
Key indicators
Percentage of affected households who correctly describe three measures to
prevent WASH-related diseases
Percentage of target population who correctly cite two critical times for
handwashing
Percentage of target population observed to use handwashing stations on

leaving communal toilets
Percentage of affected households where soap and water are available for
handwashing
Percentage of affected population who collect water from improved water sources
Percentage of households that store drinking water in clean and covered

containers
Percentage of carers who report that they dispose of children’s excreta safely
Percentage of households using incontinence products (pads, urinal bottles,

bed pans, commode chairs) who report that they dispose of excreta from adult
incontinence safely
Percentage of affected households who dispose of solid waste appropriately
Percentage of people who have provided feedback and say that their feedback
was used to adapt and improve WASH facilities and services
Local environment is free of human and animal faeces
Guidance notes
Understanding and managing WASH risks: Prioritising and reducing WASH risks
in the initial phase of a crisis can be challenging. Focus on the use of safe water,
excreta management and handwashing, as these are likely to have the greatest
97
impact on preventing disease transmission. Assessing WASH-related public health

risks and steps to reduce them will require an understanding of:
•• current use of WASH facilities and services;

•• access to essential household hygiene items ⊕ see Hygiene promotion
standards 1.2 and 1.3;
•• current coping strategies, local customs and beliefs;
•• social structures and power dynamics in the community;
•• where people go for healthcare (including traditional healers, pharmacies,
clinics);
•• who is responsible for operating and maintaining WASH infrastructure;
•• disease surveillance data linked to WASH;
•• social, physical and communication barriers to accessing WASH facilities and
services, particularly for women and girls, older people and persons with
disabilities;
•• income-level variations; and
•• environmental conditions and seasonal trends for diseases.
To maintain motivation, behavioural change and practice need to be easy.

Facilities should be convenient and accessible for all users, safe, dignified, clean
and culturally appropriate. Include both men and women in hygiene promotion
activities, as active hygiene support by men may have a decisive influence
on behaviours in the family.
Community mobilisation: Work with existing structures, ensuring that paid
or voluntary opportunities are equally available to both women and men.
Respected community and faith-based leaders, outreach workers and trusted
local actors such as women’s or youth groups can facilitate mobilisation and
preventive action.
Allocating two outreach workers per 1,000 people is common. Outreach workers
and volunteers should have good communication skills, be able to build respectful
relationships with local communities, and have a thorough understanding of local
needs and concerns. If needed, incentives for outreach workers should be agreed
through a local coordination forum to promote equity and avoid disruption.
Community health workers may have similar roles to WASH outreach workers, but
different responsibilities ⊕ see Health systems standard 1.2: Health workforce.
Working with children: Children can promote healthy behaviours to their peers
and family. The department of education or social services can identify opportu
nities to promote hygiene in schools, residential care and child-headed households,
and to children living on the street. Involve the children in developing the messages
⊕ see INEE and CPMS Handbooks.
Communication channels and approaches: Provide information in multiple formats
(written, graphic, audio) and languages to make it as widely accessible as possible.
Adapt for children and persons with disabilities and develop and test messages
98
HYGIENE PROMOTION
to ensure they are understandable across differences in age, sex, education level
and language.
Community-level dialogue is useful for problem solving and action planning.
Mass media can reinforce general information with a broader reach. Both are
useful if targeted at specific audiences. Design appropriate feedback mech
anisms with users and monitor their effectiveness. Communicate feedback to
the community, encouraging them to respond in turn ⊕ see Core Humanitarian
Standard Commitment 5.
Handwashing with soap is an important way to prevent transmission of diarrhoeal
diseases. Handwashing facilities need a regular supply of water, soap and safe
drainage. Position facilities so that handwashing happens before touching
food (eating, preparing food or feeding a child) and after contact with excreta
(after using the toilet or cleaning a child’s bottom) ⊕ see Water supply standard 2.2:
Water quality.
Promoting the use of toilets: A key issue for hygiene promotion staff is the inclu
sive use of excreta disposal facilities and materials. In addition to concerns about
cleanliness and smell, major deterrents for people using toilets are embarrass
ment, cultural taboos, physical accessibility and concerns about privacy and safety
⊕ see Excreta management standard 3.2: Access to and use of toilets.
Collecting, transporting and storing drinking water safely is key to reducing
contamination risks. Households need separate containers for collecting and
storing drinking water ⊕ see Hygiene promotion standard 1.2 and Water supply
standards 2.1 and 2.2.
People on the move: Find opportunities to engage with people on the move, either by
travelling with them temporarily or meeting them at rest areas. Use communication
channels such as radio, SMS, social media groups and free hotlines to provide hygiene
information and solicit feedback. Design the “household items” package to support
this by including mobile phones or solar chargers, which will also enable people to
communicate with their families, access information and provide feedback.

Identification, access to and use of hygiene items
Appropriate items to support hygiene, health, dignity and well-being are
available and used by the affected people.
Key actions
1.
1 Identify the essential hygiene items that individuals, households and
communities need.
•• Consider different needs of men and women, older people, children and
persons with disabilities.
99
•• Identify and provide additional communal items for maintaining environmental

hygiene, such as solid waste receptacles and cleaning equipment.
2.
2 Provide timely access to essential items.
•• Assess availability of items through local, regional or international markets.
3.
3 Work with affected populations, local authorities and other actors to plan
how people will collect or buy hygiene items.
•• Provide information about timing, location, content and intended recipients
of cash-based assistance and/or hygiene items.
•• Coordinate with other sectors to provide cash-based assistance and/or
hygiene items and decide on distribution mechanisms.
4.
4 Seek feedback from affected people on the appropriateness of the
hygiene items chosen and their satisfaction with the mechanism for
accessing them.
Key indicators
All affected households have access to the minimum quantity of essential
hygiene items:
•• two water containers per household (10–20 litres; one for collection, one
for storage);
•• 250 grams of soap for bathing per person per month;
•• 200 grams of soap for laundry per person per month;
•• Soap and water at a handwashing station (one station per shared toilet or
one per household); and
•• Potty, scoop or nappies to dispose of children’s faeces.
Percentage of affected people who report/are observed using hygiene items

regularly after distribution
Percentage of household income used to purchase hygiene items for identified

priority needs
Guidance notes
Identify essential items: Adapt hygiene items and hygiene kits to the culture
and context. Prioritise essential items in the initial phase (such as soap, water
containers, and menstruation and incontinence materials) over the “nice to
have” items (such as hair brush, shampoo, toothpaste, toothbrush). Some
groups will have specific requirements ⊕ see Guidance notes - At-risk groups
(below).
Water containers: Identify 10–20-litre water containers for collecting and
storing drinking and domestic water. The size and type of containers should be
appropriate for the age and carrying capacity of those who usually collect water.
100
HYGIENE PROMOTION
Containers should have lids, be clean and covered. Storage containers should
have a narrow neck or tap to ensure safe collection, storage and consumption of
drinking water.
If the water supply is intermittent, provide larger storage containers. In urban
settings or where supplies are centralised, household storage should be
enough for ordinary consumption (including peak consumption, where relevant)
between refills.
At-risk groups: Some people will need different or greater quantities of personal
hygiene items because of their age, health status, disability, mobility or incon
tinence. Persons with disabilities or who face barriers to mobility may need
additional items. This includes extra soap, incontinence items, water containers,
bed pans, a commode chair or plastic covers for mattresses. Ask people or their
carers if they need help collecting and disposing of their waste in a way that
respects their dignity. Consult with them and their families or carers on the most
appropriate support.
Market-based programming for hygiene items: Provision of hygiene items
should support local markets where possible (for example by providing cash or
vouchers or improving warehouse infrastructure). A market assessment and
household income analysis, including gender roles in expenditure decisions,
should inform the plans for access and use of hygiene items. Monitor whether
or not the market is providing the quantity and quality of products, and adjust if
necessary ⊕ see Delivering assistance through markets.
Distribution: Prioritise the safety and security of the population when organising
any distribution ⊕ see Protection Principle 1.
Set up a dedicated distribution team. Inform people in advance of the timing,
location, list of items and any eligibility criteria. Counter discrimination or
stigmatisation and, if necessary, distribute to households or through separate
distribution lines. Identify and address any barriers to accessing distribution
locations or distribution systems, specifically for women and girls, older people
and persons with disabilities.
Replenish consumables: Establish a reliable regular supply of consumables such as
soap and menstruation and incontinence materials.
Coordination of joint distributions: Plan shared community consultations to
understand needs and coping mechanisms across sectors. Address multiple
needs at the same time for the convenience of the target population and to save
time and money across sectors. Ensure that households can safely transport
home all their items following distribution.
People on the move: Where people are on the move, confirm transportability of
hygiene items (such as travel-sized soap). Let people select the items they want,
rather than issuing standardised kits. Establish a system to collect and dispose of
packaging waste where people are on the move.
101

Menstrual hygiene management and incontinence
Women and girls of menstruating age, and males and females with incon
tinence, have access to hygiene products and WASH facilities that support
their dignity and well-being.
Key actions
1.
1 Understand the practices, social norms and myths concerning menstrual
hygiene management and incontinence management, and adapt hygiene
supplies and facilities.
2.
2 Consult women, girls and people with incontinence on the design, siting
and management of facilities (toilets, bathing, laundry, disposal and
water supply).
3.
3 Provide access to appropriate menstrual hygiene management and
incontinence materials, soap (for bathing, laundry and handwashing) and
other hygiene items.
•• For distributions, provide supplies in discrete locations to ensure dignity and
reduce stigma, and demonstrate proper usage for any unfamiliar items.
Key indicators
Percentage of women and girls of menstruating age provided with access to
appropriate materials for menstrual hygiene management
Percentage of recipients who are satisfied with menstrual hygiene manage-

ment materials and facilities
Percentage of people with incontinence that use appropriate incontinence

materials and facilities
Percentage of recipients that are satisfied with incontinence management

materials and facilities
Guidance notes
Addressing menstrual hygiene management and incontinence in crises: Successfully
managing menstrual hygiene and incontinence helps people to live with dignity
and engage in daily activities. In addition to providing access to hygiene items, it
is important to consult with users about disposal mechanisms at home as well as
in communal facilities and institutions such as schools. Toilet facilities should be
adapted and space provided for laundry and drying facilities ⊕ see Excreta manage-
ment standards 3.1 and 3.2.
102
HYGIENE PROMOTION
Taboos about menstruation: Menstruation beliefs, norms and taboos will affect the
success of the response. Investigating these issues may not be possible during the
initial or acute phase of the crisis, but it should be done as soon as possible.
Incontinence may not be a widely used term in some contexts, even within the
medical profession. Incontinence is a complex health and social issue that occurs
when a person is unable to control the flow of their urine or faeces. It can lead to a
high level of stigma, social isolation, stress and an inability to access services, educa
tion and work opportunities. Prevalence may seem low, as many people will keep it a
secret, yet a wide range of people may live with incontinence. This includes:
•• older people;
•• persons with disabilities and those facing mobility barriers;
•• women who have given birth–including girls, who are at increased risk
of fistula;
•• people with chronic illnesses such as asthma, diabetes, stroke or cancer;
•• girls and women who have experienced gender-based violence or have
undergone female genital mutilation;
•• people who have had surgery such as removal of the prostate;
•• women going through the menopause; and
•• young children and children psychologically affected by conflict or disaster.
Poor incontinence hygiene management can be a major source of disease trans

mission in emergencies. Access to much higher amounts of water and soap is
critical. People with incontinence and their carers each need five times as much
soap and water as others. People who are incontinent and immobile need to
consult health or disability specialists to learn how to prevent and manage
infections and bed sores, which can be fatal.
Supplies and facilities: Discuss options with affected people to understand their
preferences for: disposable or reusable materials; disposal mechanisms in homes,
schools, health centres and communal facilities; laundry and drying facilities; and
toilet and bathing facilities. Consider age-specific norms and preferences, as the
type and quantity of supplies may change over time. Provide demonstrations for
unfamiliar materials.
Different types of pads are required for faecal and urine incontinence, and for
different levels of severity of incontinence. Sizing is important for safe use. Supply
both urine and faecal incontinence pads in a range of sizes and types.
Consider proximity to toilets for people with incontinence. Some people may be
able to prevent incontinence episodes if they can access the toilet quickly. A toilet
commode chair, bed pan and/or urinal bottle may need to be supplied.
Minimum supplies: For both menstrual hygiene management and incontinence:
•• a dedicated container with lid for soaking cloths and storing pads/cloths; and
•• rope and pegs for drying.
103
For menstrual hygiene:

•• either absorbent cotton material (4 square metres per year), disposable
pads (15 per month) or reusable sanitary pads (six per year), as preferred by
women and girls;
•• underwear (six per year);
•• extra soap (250 grams per month) ⊕ see Hygiene promotion standard 1.2:
Identification, access to and use of hygiene items.
For incontinence, supplies will depend on the severity and type of incontinence and
people’s preferences. A suggested minimum is:
•• either absorbent soft cotton material (8 square metres per year), disposable
incontinence pads (150 per month) or reusable incontinence underwear
(12 per year);
•• underwear (12 per year);
•• extra soap (500 grams bathing and 500 grams laundry per month);
•• two washable leak-proof mattress protectors;
•• additional water containers;
•• bleach or similar disinfectant cleaning product (3 litres of non-diluted
product per year);
•• bed pan and urinal bottles (male and female), toilet commode chair (as
appropriate).
Replenishment of supplies: Plan how and when to replenish materials. Cash-based
assistance or in-kind distributions may be used in different ways over time. Explore
options for small enterprises to provide materials or for people to make their own
protection materials ⊕ see Delivering assistance through markets.
Schools, safe spaces and learning centres: Support for WASH in schools and safe
spaces should consider the WASH infrastructure and the training provided to
teachers. Facilities should have a discrete disposal mechanism a container with
a lid, with collection and disposal system or a chute from the toilet to an inciner
ator. Install well-maintained and sex-segregated WASH facilities with hooks and
shelves for menstrual hygiene supplies.
Encourage teachers to adopt menstrual hygiene management education as part of
standard lessons. Train teachers to:
•• support girls’ menstrual hygiene practices;
•• keep menstrual hygiene supplies at school;
•• support students who experience incontinence due to the psychological
effects of the crisis ⊕ see INEE Handbook.
Shelter: Work with the shelter sector to ensure there is adequate privacy for
menstrual hygiene and incontinence management in the household or communal
shelter. This may include using privacy screens or separate areas for changing.
People on the move: Offer menstrual hygiene and incontinence management
supplies as people pass through supply points.
104
Water supply
2. Water supply
Inadequate water quantity and quality is the underlying cause of most public
health problems in crisis situations. There may not be sufficient water available to
meet basic needs, so supplying a survival level of safe drinking water is essential.
The priority is to provide an adequate quantity of water, even if it is of intermediate
quality. This may be necessary until Minimum Standards for both water quantity
and quality are met.
Taps, wells and pipes often fall into disrepair due to conflict, natural disaster or
lack of functional maintenance systems. In conflict, depriving access to water
may be used as an intentional strategy by parties to the conflict. This is strictly
prohibited in international humanitarian law.
Consult community members and relevant stakeholders to understand how they
use and access water, whether there are any access limitations, and how these
may change seasonally.
Water supply standard 2.1:

Access and water quantity
People have equitable and affordable access to a sufficient quantity of safe
water to meet their drinking and domestic needs.
Key actions
1.
1 Identify the most appropriate groundwater or surface water sources, taking
account of potential environmental impacts.
•• Consider seasonal variations in water supply and demand, and mechanisms
for accessing drinking water, domestic water and water for livelihoods.
•• Understand different sources of water, suppliers and operators, and access
to water within communities and households.
2.
2 Determine how much water is required and the systems needed to deliver it.
•• Work with stakeholders to locate waterpoints that allow safe and equitable
access for all community members.
•• Establish operation and maintenance systems that assign clear responsi
bilities and include future needs for sustainable access.
3.
3 Ensure appropriate waterpoint drainage at household and communal
washing, bathing and cooking areas and handwashing facilities.
•• Look for opportunities to reuse water, such as for vegetable gardens,
brick-making or irrigation.
105
Key indicators
Average volume of water used for drinking and domestic hygiene per household
•• Minimum of 15 litres per person per day
•• Determine quantity based on context and phase of response
Maximum number of people using water-based facility

•• 250 people per tap (based on a flow rate of 7.5 litres/minute)
•• 500 people per hand pump (based on a flow rate of 17 litres/minute)
•• 400 people per open hand well (based on a flow rate of 12.5 litres/minute)
•• 100 people per laundry facility
•• 50 people per bathing facility
Percentage of household income used to buy water for drinking and domestic
hygiene
•• Target 5 per cent or less
Percentage of targeted households who know where and when they will next
get their water
Distance from any household to the nearest waterpoint

•• <500 metres
Queuing time at water sources

•• <30 minutes
Percentage of communal water distribution points free of standing water
Percentage of water systems/facilities that have functional and accountable

management system in place
Guidance notes
Water source selection should consider:
•• availability, safety, proximity and sustainability of a sufficient quantity
of water;
•• need for and feasibility of water treatment, whether bulk or at household
level; and
•• social, political or legal factors affecting the source control of water sources
might be controversial, especially during conflicts.
A combination of approaches and sources is often required in the initial phase of a
crisis to meet survival needs. Surface water sources, despite requiring more treat
ment, may be the quickest solution. Groundwater sources and/or gravity-flow
supplies from springs are preferable. They require less treatment, and gravity-flow
does not require pumping. Monitor all sources regularly to avoid over-extraction
⊕ see Shelter and settlement standard 2: Location and settlement planning.
106
Water supply
Needs: The quantity of water needed for drinking, hygiene and domestic use
depends upon the context and phase of a response. It will be influenced by factors
such as pre-crisis use and habits, excreta containment design and cultural habits
⊕ see Understanding and managing WASH risks in Hygiene promotion standard 1.1 and
Excreta management standard 3.2.
A minimum of 15 litres per person per day is established practice. It is never a
“maximum” and may not suit all contexts or phases of a response. For example,
it is not appropriate where people may be displaced for many years. In the acute
phase of a drought, 7.5 litres per person per day may be appropriate for a short
time. In an urban middle-income context, 50 litres per person per day may be the
minimum acceptable amount to maintain health and dignity.
The consequences of providing different quantities of water should be reviewed
against morbidity and mortality rates for WASH-related diseases. Coordinate with
other WASH actors to agree on a common minimum for quantity in context. For
guidance on determining water quantities for human, livestock, institutional and
other uses ⊕ see Essential healthcare – communicable diseases standards 2.1.1 to 2.1.4
and WASH Appendix 3. For emergency livestock water needs ⊕ see LEGS Handbook.
Needs Quantity (litres/person/day) Adapt to context based on

Survival: water intake 2.5–3 Climate and individual physiology
(drinking and food)
Hygiene practices 2–6 Social and cultural norms
Basic cooking 3–6 Food type and social and cultural
norms
Total basic water 7.5–15
Minimum basic survival water needs: Water needs will vary within the population,
particularly for persons with disabilities or facing mobility barriers, and among
groups with different religious practices.
Measurement: Do not simply divide the quantity of delivered water by the popu
lation served. Household surveys, observation and community discussion groups
are more effective methods of collecting data on water use and consumption than
measuring the volume of water trucked or pumped, or handpump use. Triangulate
water system reports with household reports.
Access and equity: Waterpoints include communal bathing, cooking and laundry
facilities and toilets, as well as institutional settings such as schools or health
facilities.
The minimum quantity targets (see key indicators above) assume that the
waterpoint is accessible for about 8 hours a day of constant water supply.
Use these targets with caution, as they do not guarantee a minimum quantity
of water or equitable access.
107
Water and sanitation responses should address the needs of both host and
displaced populations equitably to avoid tension and conflict.
During design, consider that needs vary across age groups and sex, as well as
for persons with disabilities or those facing mobility barriers. Locate accessible
waterpoints sufficiently close to households to limit exposure to any protec
tion risks.
Inform the affected population of when and where to expect the delivery of water,
their entitlement to equitable distribution, and how to give feedback.
Round-trip and queuing time: Excessive round-trip and queuing times indicate
an inadequate number of waterpoints or inadequate yields at water sources.
This can lead to reduced individual water consumption and increased consump
tion from unprotected surface sources, and result in less time for tasks such
as education or income-generating activities. Queuing time also affects the risk
of violence at the tap stand ⊕ see Protection Principle 1 and Core Humanitarian
Appropriate water containers: ⊕ See Hygiene promotion standard 1.2: Identification,
access to and use of hygiene items. Where household-level water treatment and
safe storage (HWTSS) is used, adjust the number and size of containers. For exam
ple, a coagulant, flocculation and disinfection process will require two buckets,
a straining cloth and a stirrer.
Market-based programming for water: Analyse how households accessed water
and containers before and after the crisis. This simple market assessment should
inform decisions about how to provide sustainable access to water in the short
and long term. Determine how to use, support and develop the water market,
considering a combined approach of household cash-based assistance, grants and
technical capacity building with vendors or suppliers, or other means. Track the
monthly market prices (water, fuel) for household expenditure over time, and use
these trends to inform changes in programme design ⊕ see Delivering assistance
through markets.
Payment: Water costs should be no more than 3–5 per cent of household income.
Be aware of how households are covering higher costs during the crisis and take
steps to counter negative coping mechanisms ⊕ see Protection Principle 1. Ensure
that finance systems are managed in a transparent way.
Management of the water systems and infrastructure: Work with the community
and other stakeholders to decide on the siting, design and use of waterpoints
(both immediate and long-term plans). This includes bathing, cooking and laundry
facilities, toilets, and institutions such as schools, markets and health facilities.
Use feedback to adapt and improve access to water facilities.
Consider the previous and current water governance structures, the ability and
willingness of people to pay for water and sanitation services, and cost-recovery
108
Water supply
mechanisms. Consider capital investment in water supply systems that offer

longer-term savings or economies of scale. Compare alternatives such as solar
pumping or a piped water system with water trucking, especially in protracted
crises in urban areas and communal settlements.
Provide people with the means to operate and maintain water systems through
WASH committees or partnerships with the private or public sector.
Use of bottled water: Treated water is more cost-effective, appropriate and tech
nically sound than bottled water, because of transport, cost, quality and waste
generation. Exceptions can be made for the short term (for example, people on the
move). Establish an appropriate plastic waste management system.
Laundry, washing and bathing facilities: If household private bathing is not
possible, provide separate facilities for men and women that ensure safety,
privacy and dignity.
Consult with the users, particularly women, girls and persons with disabilities, to
decide the location, design and safety of facilities. Consider access to hot water for
bathing and laundry during specific contexts, such as responding to scabies, and
during climatic variations.
Drainage from waterpoints, laundry areas, bathing facilities and handwashing
stations: In constructing and rehabilitating water distribution and usage points,
ensure that wastewater does not pose a health hazard or breeding ground
for problem vectors. Establish an overall drainage plan in coordination with site
planners, the shelter sector and/or municipal authorities.
Design WASH systems and infrastructure to comply with the drainage require
ments. For instance, the pressure rating at tap stands, the size of the waterpoint
and/or laundry apron, and the height from the tap to the bottom of the water
containers should be appropriate ⊕ see Shelter and settlement standard 2: Location
and settlement planning.
Water supply standard 2.2:

Water quality
Water is palatable and of sufficient quality for drinking and cooking, and for
personal and domestic hygiene, without causing a risk to health.
Key actions
1.
1 Identify public health risks associated with the water available and the most
appropriate way to reduce them.
•• Protect water sources and regularly renew sanitary surveys at source and
water points.
109
2.
2 Determine the most appropriate method for ensuring safe drinking water at
point of consumption or use.
•• Treatment options include bulk water treatment and distribution, with safe
collection and storage at the household level, or household-level water
treatment and safe storage.
3.
3 Minimise post-delivery water contamination at point of consumption or use.
•• Equip households with safe containers to collect and store drinking water,
and the means to safely draw water for drinking.
•• Measure water quality parameters (free residual chlorine (FRC) and coliform-
forming units (CFU)) at point of delivery and point of consumption or use.
Key indicators
Percentage of affected people who collect drinking water from protected
water sources
Percentage of households observed to store water safely in clean and covered

containers at all times
Percentage of water quality tests meeting minimum water quality standards

•• <10 CFU/100ml at point of delivery (unchlorinated water)
•• ≥0.2–0.5mg/l FRC at point of delivery of delivery (chlorinated water)
•• Turbidity of less than 5 NTU
Guidance notes
Maintaining a safe water chain: Water-related diseases pose a risk to the integ
rity of the water chain. The barriers to faecal–oral transmission include excreta
containment, covering food, handwashing at key times, and safe collection and
storage of water ⊕ see Hygiene promotion standard 1.1; Excreta management
standard 3.2 and Appendix 2: The F diagram.
A risk assessment of the water chain, from the water source to the drinking water
storage container, includes:
1. sanitary survey of the waterpoint;

2. observation of use of separate containers for water collection and storage;
3. observation of clean and covered drinking water containers; and
4. water quality testing.
Where there is a high likelihood of unsafe water, these actions can highlight
apparent risks without carrying out labour-intensive household water-quality
testing.
A sanitary survey assesses conditions and practices that may constitute a
public health risk at the water point. It considers the structure of the water point,
110
Water supply
drainage, fencing, defaecation practices and solid waste management practices as

possible sources of contamination. The survey also examines water containers in
the household.
Water quality: When commissioning a new water source, test the water for
physical, bacteriological and chemical parameters. Do this before and after local
seasonal fluctuations. Do not neglect the analysis of chemical parameters
(such as fluoride and arsenic levels) that can lead to long-term health issues.
Faecal coliform bacteria (>99 per cent of which are E. coli) indicate the level of human
and animal waste contamination in water and the possible presence of other harmful
pathogens. If any faecal coliforms are present, treat the water. Even if E. coli is not
found, water is prone to recontamination without a residual disinfectant.
Where water is chlorinated (prior to distribution or household-level treatment)
carry out spot checks in households by measuring FRC and treat where necessary.
The frequency of water delivery, temperature and length of time water is stored all
affect household FRC measurements (chlorine dissipation).
Promoting protected sources: People may prefer unprotected water sources such
as rivers, lakes and unprotected wells for reasons of taste, proximity and social
convenience. Understand their rationale and develop messages and activities that
promote protected water sources.
Palatable water: If safe drinking water does not taste good (due to salinity,
hydrogen sulfide or chlorine levels that people are not used to), users may
drink from better-tasting but unsafe sources. Use community engagement and
hygiene activities to promote safe drinking water.
Water disinfection: Water should be treated with a residual disinfectant such
as chlorine if there is a significant risk of source or post-delivery contamination.
The risk will be determined by population density, excreta disposal arrangements,
hygiene practices and the prevalence of diarrhoeal disease. Turbidity should
be below 5 NTU. If it is higher, train users to filter, settle and decant the water to
reduce turbidity before treatment. Consider short-term double-dose chlorination
if there is no alternative. Be aware that chlorine dissipation varies depending on
the length of storage and temperature range, so factor this into dosing and contact
times ⊕ see Appendix 6: Household water treatment and storage decision tree.
Quantity versus quality: If it is not possible to meet Minimum Standards for both
water quantity and quality, prioritise quantity over quality. Even water of inter
mediate quality can be used to prevent dehydration, decrease stress and prevent
diarrhoeal diseases.
Post-delivery contamination: Water that is safe at the point of delivery can become
contaminated during collection, storage and drawing of drinking water. Minimise
this through safe collection and storage practices. Clean household or settlement
storage tanks regularly and train the community to do so ⊕ see Hygiene promotion
standards 1.1 and 1.2.
111
Household-level water treatment and safe storage (HWTSS): Use HWTSS when a
centrally operated water treatment system is not possible. HWTSS options that
reduce diarrhoea and improve the microbiological quality of stored household
water include boiling, chlorination, solar disinfection, ceramic filtration, slow
sand filtration, membrane filtration, and flocculation and disinfection. Work with
other sectors to agree household fuel requirements and access for boiling water.
Avoid introducing an unfamiliar water treatment option in crises and in epidemics.
Effective use of HWTSS options requires regular follow-up, support and moni
toring, and is a prerequisite to adopting HWTSS as an alternative water treatment
approach ⊕ see Appendix 6: Household water treatment and storage decision tree.
Water quality for institutions: Treat all water supplies for schools, hospitals,
health centres and feeding centres with chlorine or another residual disinfectant
⊕ see Appendix 3: Minimum water quantities: survival figures and quantifying
water needs.
Chemical and radiological contamination: Where hydrogeological records or
knowledge of industrial or military action suggest that water supplies may
carry chemical or radiological public health risks, carry out a chemical analysis.
A decision to use possibly contaminated water for longer-term supplies should
only follow a thorough analysis of the health implications and validation with
the local authorities.
112
Excreta management
3. Excreta management
An environment free of human excreta is essential for people’s dignity, safety,
health and well-being. This includes the natural environment as well as the living,
learning and working environments. Safe excreta management is a WASH priority.
In crisis situations, it is as important as providing a safe water supply.
All people should have access to appropriate, safe, clean and reliable toilets.
Defaecation with dignity is a highly personal matter. Appropriateness is deter
mined by cultural practices, people’s daily customs and habits, perceptions, and
whether individuals have used sanitation facilities before. Uncontrolled human
defaecation constitutes a high risk to health, particularly where population density
is high, where people are displaced, and in wet or humid environments.
Different terms are used in the WASH sector to define excreta management
facilities. In this Handbook, “toilet” means any facility or device that immediately
contains excreta and creates the first barrier between people and the waste ⊕ see
Appendix 2: The F diagram. The word “toilet” is used in place of the word “latrine”
throughout the Handbook.
Containment of human excreta away from people creates an initial barrier to
excreta-related disease by reducing direct and indirect routes of disease trans
mission ⊕ see Appendix 2: The F diagram. Excreta containment should be integrated
with collection, transport, treatment and disposal to minimise public health risks
and environmental impact.
Evidence of human faeces in the living, learning and working environment can
indicate protection issues. People may not feel safe using facilities, especially in
densely populated areas.
For this chapter, “human excreta” is defined as waste matter discharged from the
body, especially faeces, urine and menstrual waste. The standards in this section
cover the whole excreta chain, from initial containment to ultimate treatment.
Excreta management standard 3.1:

Environment free from human excreta
All excreta is safely contained on-site to avoid contamination of the natural,
living, learning, working and communal environments.
Key actions
1.
1 Establish facilities in newly constructed communal settlements or
those with substantially damaged infrastructure to immediately contain
excreta.
113
2.
2 Decontaminate any faeces-contaminated living, learning and working spaces
or surface water sources immediately.
3.
3 Design and construct all excreta management facilities based on a risk
assessment of potential contamination of any nearby surface water or
groundwater source.
•• Assess the local topography, ground conditions and groundwater and
surface water (including seasonal variations) to avoid contaminating water
sources and inform technical choices.
4.
4 Contain and dispose of children’s and babies’ faeces safely.
5.
5 Design and construct all excreta management facilities to minimise access to
the excreta by problem vectors.
Key indicators
There are no human faeces present in the environment in which people live,
learn and work
All excreta containment facilities are sited appropriately and are an adequate
distance from any surface or groundwater source
Guidance notes
Phasing: Immediately after a crisis, control indiscriminate open defaecation as a
matter of urgency. Establish defaecation areas, site and build communal toilets,
and start a concerted hygiene campaign. Prevent defaecation near all water sources
(whether used for drinking or not) and water storage and water treatment facilities.
Do not establish defaecation areas uphill or upwind of settlements. Do not establish
them along public roads, near communal facilities (especially health and nutrition
facilities) or near food storage and preparation areas.
Conduct a hygiene promotion campaign that encourages safe excreta disposal and
creates a demand for more toilets.
In urban crises, assess the extent of damage to existing sewerage systems.
Consider installing portable toilets or use septic or containment tanks that can be
regularly desludged.
Distance from water sources: Ensure faecal material from containment facilities
(trench latrines, pits, vaults, septic tanks, soakaway pits) does not contaminate water
sources. Faecal contamination is not an immediate public health concern unless the
water source is consumed, but environmental damage must be avoided.
Where possible, conduct soil permeability tests to determine the speed at
which waste moves through the soil (infiltration rate). Use this to determine
the minimum distance between containment facilities and water sources.
114
Excreta management
The infiltration rate will depend on soil saturation levels, any extraction from
the source, and the nature of the excreta (more watery excreta will travel faster
than less watery excreta).
If soil permeability tests cannot be conducted, the distance between contain
ment facilities and water sources should be at least 30 metres, and the
bottom of pits should be at least 1.5 metres above the groundwater table.
Increase these distances for fissured rocks and limestone, or decrease them
for fine soils.
In high groundwater table or flood situations, make the containment infrastructure
watertight to minimise groundwater contamination. Alternatively, build elevated
toilets or septic tanks to contain excreta and prevent it from contaminating the
environment. Prevent drainage or spillage from septic tanks from contaminating
surface water or groundwater sources.
If contamination is suspected, immediately identify and control the source
of contamination and initiate water treatment. Some water contaminants
can be managed with purification treatment methods such as chlorination.
However, the source of contaminants such as nitrates needs to be identified
and controlled. Methaemoglobinaemia is an acute but reversible condition
associated with high nitrate levels in drinking water, for instance ⊕ see Water
supply standard 2.2: Water quality.
Containment of children’s faeces: Infants’ and children’s faeces are commonly
more dangerous than those of adults. Excreta-related infection among children is
frequently higher, and children may not have developed antibodies to infections.
Provide parents and caregivers with information about safe disposal of infants’
faeces, laundering practices and the use of nappies (diapers), potties or scoops to
manage safe disposal.

Access to and use of toilets
People have adequate, appropriate and acceptable toilets to allow rapid, safe
and secure access at all times.
Key actions
1.
1 Determine the most appropriate technical options for toilets.
•• Design and construct toilets to minimise safety and security threats to users
and maintenance workers, especially women and girls, children, older people
and persons with disabilities.
•• Segregate all communal or shared toilets by sex and by age where
appropriate.
115
2.
2 Quantify the affected population’s toilets requirements based on public
health risks, cultural habits, water collection and storage.
3.
3 Consult representative stakeholders about the siting, design and implemen
tation of any shared or communal toilets.
•• Consider access and use by age, sex and disability; people facing mobility
barriers; people living with HIV; people with incontinence; and sexual or
gender minorities.
•• Locate any communal toilets close enough to households to enable safe
access, and distant enough so that households are not stigmatised by
proximity to toilets.
4.
4 Provide appropriate facilities inside toilets for washing and drying or disposal
of menstrual hygiene and incontinence materials.
5.
5 Ensure that the water supply needs of the technical options can be
feasibly met.
•• Include adequate supply of water for handwashing with soap, for anal
cleansing, and for flush or hygienic seal mechanisms if selected.
Key indicators
Ratio of shared toilets
•• Minimum 1 per 20 people
Distance between dwelling and shared toilet

•• Maximum 50 metres
Percentage of toilets that have internal locks and adequate lighting
Percentage of toilets reported as safe by women and girls
Percentage of women and girls satisfied with the menstrual hygiene manage-
ment options at toilets they regularly use
Guidance notes
What is adequate, appropriate and acceptable? The type of toilet adopted will
depend on the phase of the response, preferences of the intended users, existing
infrastructure, the availability of water for flushing and water seals, the soil form
ation and the availability of construction materials.
Generally, toilets are adequate, appropriate and acceptable if they:
•• are safe to use for all of the population, including children, older people,
pregnant women and persons with disabilities;
•• are located to minimise security threats to users, especially to women and
girls and people with other specific protection concerns;
116
Excreta management
•• are no more than 50 metres from dwellings;

•• provide privacy in line with users’ expectations;
•• are easy to use and keep clean (generally, clean toilets are used more
frequently);
•• do not present a hazard to the environment;
•• have adequate space for different users;
•• have inside locks;
•• are provided with easy access to water for handwashing, anal cleansing
and flushing;
•• allow for the dignified cleaning, drying and disposal of women’s menstrual
hygiene materials, and child and adult incontinence materials;
•• minimise fly and mosquito breeding; and
•• minimise smell.
Provide people who have chronic illnesses, such as HIV, with easy access to a toilet.
They frequently suffer from chronic diarrhoea and reduced mobility.
Monitor use and the percentage of people who report that the toilets meet their
requirements. Use this information to understand which groups are not satisfied
and how to improve the situation. Consider access and use by sex and age, persons
with disabilities or facing mobility barriers, people living with HIV and people with
incontinence.
Accessibility: The technical option chosen should respect the right of all people,
including persons with disabilities, to safely access sanitation facilities. Accessible
toilets, or additions to existing toilets, may need to be constructed, adapted or
bought for children, older people and persons with disabilities or incontinence.
As a guide, single-access gender-neutral toilets with ramps or level entries, with
enhanced accessibility inside the superstructure, should also be made available
at a minimum ratio of 1 per 250 people.
Safe and secure facilities: Inappropriate siting of toilets may make women and
girls more vulnerable to attack, especially at night. Ensure that all at-risk groups,
including women and girls, boys, older people and others with specific protec
tion concerns feel and are safe when using the toilets during both day and night.
Adequately light facilities and consider providing at-risk groups with torches. Ask
the community, especially those most at risk, how to enhance their safety. Consult
stakeholders from schools, health centres and clinics, child-friendly spaces,
marketplaces and nutrition feeding centres.
Note that it is not sufficient to consult only with women and children about safe
and dignified WASH facilities, as in many contexts men control what women and
children are allowed to do. Be aware of these social hierarchies and power dynam
ics, and actively engage with decision-makers to reinforce the right of women and
children to safely access toilets and showers.
117
Lighting at communal facilities can improve access but can also attract people to
use the lighting for other purposes. Work with the community, especially those
most at risk of threats to their safety, to find additional ways to reduce their
exposure to risks.
Quantifying toilet requirements: Consider how to adapt toilet requirements in
context to reflect changes in the living environment before and after the crisis,
requirements in public areas and any specific public health risks. During the
first phases of a rapid-onset crisis, communal toilets are an immediate solu-
tion with a minimum ratio of 1 per 50 people, which must be improved as soon
as possible. A medium-term minimum ratio is 1 per 20 people, with a ratio of
3:1 for female to male toilets . For planning figures and number of toilets ⊕ see
Appendix 4.
Household, shared or communal? Household toilets are considered the ideal in
terms of user safety, security, convenience and dignity, and the demonstrated
links between ownership and maintenance. Sometimes shared facilities for a
small group of dwellings may be the norm. Communal or shared toilets can
be designed and built with the aim of ensuring household toilets in future.
For example, leaving sanitation corridors in settlements provides the space to
build communal facilities close to shelters and then build household facilities as
budgets allow. Sanitation corridors ensure access for desludging, maintenance
and decommissioning.
Communal toilets will also be necessary in some public or communal spaces such
as health facilities, market areas, feeding centres, learning environments and
reception or administrative areas ⊕ see Appendix 4: Minimum numbers of toilets:
community, public places and institutions.
Communal sanitation facilities built during a rapid response will have
specific operation and maintenance requirements. Payment for toilet cleaners
may be agreed with communities as a temporary measure, with a clear exit
strategy.
Water and anal cleansing material: In designing the facility, ensure enough
water, toilet paper or other anal cleansing material is available. Consult users
about the most appropriate cleansing material and ensure safe disposal and
sustainability of supply.
Handwashing: Ensure that the facility allows for handwashing, including water
and soap (or an alternative such as ash) after using toilets, cleaning the bottom
of a child who has defecated, and before eating and preparing food.
Menstrual hygiene management: Toilets should include appropriate containers
for the disposal of menstrual materials in order to prevent blockages of sewer
age pipes or difficulties in desludging pits or septic tanks. Consult with women
and girls on the design of toilets to provide space, access to water for washing,
and drying areas.
118
Excreta management

Management and maintenance of excreta collection,
transport, disposal and treatment
Excreta management facilities, infrastructure and systems are safely
managed and maintained to ensure service provision and minimum impact
on the surrounding environment.
Key actions
1.
1 Establish collection, transport, treatment and disposal systems that align
with local systems, by working with local authorities responsible for excreta
management.
•• Apply existing national standards and ensure that any extra load placed
on existing systems does not adversely affect the environment or
communities.
•• Agree with local authorities and landowners about the use of land for any
off-site treatment and disposal.
2.
2 Define systems for short- and long-term management of toilets, especially
sub-structures (pits, vaults, septic tanks, soakage pits).
•• Design and size sub-structures to ensure that all excreta can be safely
contained and the pits desludged.
•• Establish clear and accountable roles and responsibilities and define sources
of finance for future operation and maintenance.
3.
3 Desludge the containment facility safely, considering both those doing the
collection and those around them.
4.
4 Ensure that people have the information, means, tools and materials to
construct, clean, repair and maintain their toilets.
•• Conduct hygiene promotion campaigns on the use, cleaning and maintenance
of toilets.
5.
5 Confirm that any water needed for excreta transport can be met from
available water sources, without placing undue stress on those sources.
Key indicator
All human excreta is disposed of in a manner safe to public health and the
environment
Guidance notes
Desludging is the removal of (untreated and partially treated) excreta from the
pit, vault or tank, and transport to an off-site treatment and disposal facility.
119
If desludging is required, it must be designed into operation and maintenance

processes and budgets from the start.
Sullage or domestic wastewater is classified as sewage when mixed with human
excreta. Unless the settlement is sited where there is an existing sewerage system,
domestic wastewater should not be allowed to mix with human excreta. Sewage is
difficult and more expensive to treat than domestic wastewater.
Planning: Initially, plan for an excreta volume of 1–2 litres per person per day. Long
term, plan for 40–90 litres per person per year; excreta reduces in volume as it
decomposes. Actual volume will depend on whether water is used for flushing
or not, whether material or water is used for anal cleansing, whether water and
other material is used for cleaning toilets, and the diet of the users. Ensure that
household water from cleaning and cooking or from laundry and bathing does not
enter the containment facilities, as the excess water will mean more desludging.
Allow 0.5 metres at the top of the pit for backfill.
For specific public health situations such as cholera outbreaks ⊕ see WASH
standard 6: WASH in healthcare settings.
Local markets: Use locally available materials and labour for toilet construction
where appropriate. This enhances participation in the use and maintenance of
the facilities.
Excreta containment in difficult environment: In floods or urban crises, appropriate
excreta containment facilities can be especially difficult to provide. In these
situations, consider raised toilets, urine diversion toilets, sewage containment
tanks and temporary disposable plastic bags with appropriate collection and
disposal systems. Support these different approaches with hygiene promotion
activities.
Excreta as a resource: Excreta is also a potential resource. Technology is available
to convert processed sludge into energy, for example as combustible bricks
or as biogas. Ecological sanitation or composting processes recover organic
fractions and nutrients from a combination of human waste and organic kitchen
waste. The resulting compost can be used as a soil conditioner or fertiliser for
household gardens.
120
Vector control
4. Vector control
A vector is a disease-carrying agent. Vectors create a pathway from the source
of a disease to people. Vector-borne diseases are a major cause of sickness
and death in many humanitarian settings. Most vectors are insects such as
mosquitoes, flies and lice, but rodents can also be vectors. Some vectors can
also cause painful bites. Vectors can be symptomatic of solid waste, drainage
or excreta management problems, inappropriate site selection, or broader
safety and security problems.
Vector-borne disease can be complex, and solving vector-related problems may
require specialist advice. However, simple and effective measures can prevent the
spread of such diseases.
Vector control programmes may have no impact if they target the wrong vector,
use ineffective methods, or target the right vector in the wrong place or at the
wrong time. Controls must be targeted and based on the life cycles and ecologies
of the vectors.
Control programmes should aim to reduce vector population density, vector
breeding sites, and contact between humans and vectors. In developing control
programmes, consult existing studies and seek expert advice from national and
international health organisations. Seek local advice on disease patterns, breeding
sites and seasonal variations in vector numbers and disease incidence.
The standards in this section focus on reducing or eliminating problem vectors to
prevent vector-borne disease and reduce nuisance. Vector control across multiple
sectors is required ⊕ see Shelter and settlement standard 2, Essential healthcare –
communicable diseases standard 2.1.1 and Food assistance standard 6.2.
Vector control standard 4.1:

Vector control at settlement level
People live in an environment where vector breeding and feeding sites are
targeted to reduce the risks of vector-related problems.
Key actions
1.
1 Assess vector-borne disease risk for a defined area.
•• Establish whether the area’s incidence rate is greater than the World Health
Organization (WHO) or national established norm for the disease.
•• Understand the potential vector breeding sites and life cycle, especially
feeding, informed by local expertise and knowledge of important vectors.
121
2.
2 Align humanitarian vector control actions with local vector control plans or
systems, and with national guidelines, programmes or policies.
3.
3 Determine whether chemical or non-chemical control of vectors outside
households is relevant based on an understanding of vector life cycles.
•• Inform the population about potential risks that originate from chemical
control of vectors and about the schedule for chemical application.
•• Train and equip all personnel handling chemicals with personal protective
equipment (PPE) and clothing.
Key indicator
Percentage of identified breeding sites where the vector’s life cycle is disrupted
Guidance notes
Communal settlements: Site selection is important to minimising the exposure of
the affected population to the risk of vector-borne disease. This should be one of
the key factors when considering possible sites. To control malaria, for example,
locate communal settlements 1–2 kilometres upwind from large breeding sites
such as swamps or lakes, but ensure the availability of an additional clean water
source. Consider the impact a new settlement site can have on the presence of
problem vectors in neighbouring host communities ⊕ see Shelter and settlement
standard 2: Location and settlement planning.
Assessing risk factors: Base decisions about vector control responses on an
assessment of potential disease and other risks, as well as on epidemiological
and clinical evidence of vector-borne disease problems. Review suspected and
confirmed cases during the previous two years in the defined area. Other factors
influencing this risk include:
•• immunity status of the population, including previous exposure and nutritional

and other stresses;
•• movement of people from a non-endemic to an endemic area during
displacement;
•• pathogen type and prevalence, in both vectors and humans;
•• vector species, numbers, behaviours and ecology (season, breeding sites)
and how they potentially interact; and
•• increased exposure to vectors as a result of proximity, settlement pattern,
shelter type, existing individual protection and avoidance measures.
Removing or modifying vector breeding and feeding sites: Many WASH activities
can have a major impact on breeding and feeding sites, including:
•• eliminating stagnant water or wet areas around water distribution points,

bathing areas and laundries;
122
Vector control
•• managing solid waste storage at household level, during collection and

transportation, and at treatment and disposal sites;
•• providing lids for water containers;
•• managing excreta;
•• cleaning toilet slabs and superstructures to dissuade vector presence;
•• sealing offset toilet pits to ensure no faeces enters the environment and
problem vectors do not enter the pits;
•• running hygiene promotion programmes on general cleanliness; and
•• keeping wells covered and/or treating them with larvicide, for example where
dengue fever is endemic.
The three main species of mosquitoes responsible for transmitting disease are:
•• Culex (filariasis and West Nile virus), which breed in stagnant water with
organic matter, such as in toilets;
•• Anopheles (malaria and filariasis), which breed in relatively unpolluted surface
water such as puddles, slow-flowing streams and wells; and
•• Aedes (dengue, yellow fever, chikungunya and Zika virus), which breed in
water containers such as bottles, buckets and tyres.
Biological and non-chemical control: Biological control introduces organisms
that prey on, parasitise, compete with or reduce populations of the target
vector species. For example, larvivorous fish and freshwater crustaceans can
control Aedes mosquitoes (vectors of dengue). One of the most promising
strategies is the use of Wolbachia endosymbiotic bacteria, which has been
targeted towards reducing dengue virus transmission. Biological control has
been effective in certain operational environments, and evidence points to it
being effective at scale.
While biological control avoids chemical contamination of the environment,
there may be operational limitations and undesired ecological consequences.
Biological control methods are only effective against the immature stages of
vector mosquitoes and are typically restricted to use in large concrete or glazed
clay water-storage containers or wells. The willingness of local communities
to accept the introduction of organisms into water containers is essential.
Community involvement is desirable when distributing the control organisms
and in monitoring and restocking containers when necessary.
Environmental engineering responses: Several basic environmental engineering
measures reduce vector breeding, including:
•• proper disposal of human and animal excreta, properly functioning toilets,
and keeping lids on the squatting hole of pit toilets;
•• proper disposal of solid waste to control insects and rodents;
•• ensuring good drainage in settlements; and
•• draining standing water and clearing vegetation around open canals and
ponds to control mosquitoes.
123
Such measures will reduce the population density of some vectors. It may not be
possible to have sufficient impact on all the vector breeding, feeding and resting
sites within or near a settlement, even in the longer term. If so, consider local
ised chemical control or individual protection measures. Spraying infected spaces
may reduce the number of adult flies and prevent a diarrhoea epidemic or help
to minimise the disease burden if employed during an epidemic. Indoor residual
spraying will reduce the adult density of mosquitoes transmitting malaria or
dengue. Toxic baits will reduce rodent populations.
National and international protocols: The WHO has published clear interna
tional protocols and norms that address both the choice and the application of
chemicals in vector control, as well as the protection of personnel and training
requirements. Vector control measures should address two principal concerns:
efficacy and safety. If national norms regarding the choice of chemicals fall
short of international standards, then consult with and lobby the relevant
national authority for permission to adhere to the international standards.
Protect all personnel handling chemicals by providing training, protective
clothing and bathing facilities and restricting the number of hours they spend
handling chemicals.
Coordination with malaria treatment: Implement malaria vector control strategies
simultaneously with early diagnosis and treatment with anti-malarials ⊕ see
Essential healthcare – communicable diseases standard 2.1.1: Prevention.
Vector control standard 4.2:

Household and personal actions to control vectors
All affected people have the knowledge and means to protect themselves and
their families from vectors that can cause a significant risk to health or well-being.
Key actions
1.
1 Assess current vector avoidance or deterrence practices at the household
level as part of an overall hygiene promotion programme.
•• Identify barriers to adopting more effective behaviours and motivators.
2.
2 Use participatory and accessible awareness campaigns to inform people of
problem vectors, high-risk transmission times and locations, and preventive
measures.
•• Follow up specifically with high-risk groups.
3.
3 Conduct a local market assessment of relevant and effective preventive
measures.
•• Consider strengthening markets to provide a sustainable source of preven
tive measures.
124
Vector control
•• Make a procurement, distribution and implementation plan for vector control

items in collaboration with the community, local authorities and other
sectors if local markets are unable to meet the demand.
4.
4 Train communities to monitor, report and provide feedback on problem
vectors and the vector control programme.
Key indicators
Percentage of affected people who can correctly describe modes of transmis-
sion and effective vector control measures at the household level
Percentage of people who have taken appropriate action to protect themselves

from relevant vector-borne diseases
Percentage of households with adequate protection for stored food
Guidance notes
Individual malaria protection measures: Timely, systematic protection measures
such as insecticidal tents, curtains and bed nets help protect against malaria.
Long-lasting insecticidal nets also give some protection against body and head
lice, fleas, ticks, cockroaches and bedbugs. Use other protection methods like
long-sleeved clothing, household fumigants, burning coils, aerosol sprays and
repellents against mosquitoes. Support the use of such methods for those most
at risk, such as children under five years, people with immune deficiencies and
pregnant women.
High-risk groups: Some sections of the community will be more vulnerable to
vector-related diseases than others, particularly babies and infants, older people,
persons with disabilities, sick people, and pregnant and breastfeeding women.
Identify high-risk groups and take specific action to reduce that risk. Take care to
prevent stigmatisation.
Social mobilisation and communication: Behavioural change is required at both
individual and community levels to reduce both vector larval habitats and the
adult vector population. Social mobilisation and communication activities should
be fully integrated into vector prevention and control efforts, using a wide variety
of channels.
Individual protection measures for other vectors: Good personal hygiene and regular
washing of clothes and bedding are the most effective protection against body
lice. Control infestations by personal treatment (powdering), mass laundering
or delousing campaigns. Develop and use treatment protocols for new arrivals
in the settlement. A clean household environment, effective waste disposal and
appropriate storage of cooked and uncooked food will deter rats, other rodents
and insects (such as cockroaches) from entering houses or shelters ⊕ see Hygiene
promotion standard 1.1: Hygiene promotion.
125
5. Solid waste management

Solid waste management is the process of handling and disposing of organic and
inorganic solid waste. This involves:
•• planning solid waste management systems;

•• handling, separating, storing, sorting and processing waste at source;
•• transferring to a collection point; and
•• transporting and final disposal, reuse, re-purposing or recycling.
Waste can be generated at the household, institutional or community level and

includes medical waste. It may be hazardous or non-hazardous. Inadequate solid
waste management poses a public health risk as it can create favourable habitats
for insects, rodents and other disease vectors ⊕ see Vector control standard 4.1:
Vector control at settlement level. Untreated waste can pollute surface water and
groundwater. Children may play in poorly managed solid waste, risking injury or
sickness. Waste pickers, who earn money from collecting reusable materials from
waste dumps, may be at risk of injury or infectious disease.
Solid waste can block drainage systems, generating stagnant and polluted
surface water, which may be a habitat for vectors and create other public
health risks.
These standards do not cover treatment or disposal of chemical effluents or
leachates. For sources of advice on handling and treating hazardous waste
⊕ see References and further reading. For sources of advice on handling and
treating hazardous waste. For medical waste ⊕ see WASH standard 6: WASH in
healthcare settings.
Solid waste management standard 5.1:

Environment free from solid waste
Solid waste is safely contained to avoid pollution of the natural, living,
learning, working and communal environments.
Key actions
1.
1 Design the solid waste disposal programme based on public health risks,
assessment of waste generated by households and institutions, and
existing practice.
•• Assess capacities for local reuse, re-purposing, recycling or composting.
•• Understand the roles of women, men, girls and boys in solid waste manage
ment to avoid creating additional protection risks.
126
Solid waste management
2.
2 Work with local or municipal authorities and service providers to make
sure existing systems and infrastructure are not overloaded, particularly
in urban areas.
•• Ensure new and existing off-site treatment and disposal facilities can be
used by everyone.
•• Establish a timeline for complying as quickly as possible with local health
standards or policies on solid waste management.
3.
3 Organise periodic or targeted solid waste clean-up campaigns with the
necessary infrastructure in place to support the campaign.
4.
4 Provide protective clothing for and immunise people who collect and dispose
of solid waste and those involved in reuse or re-purposing.
5.
5 Ensure that treatment sites are appropriately, adequately and safely
managed.
•• Use any safe and appropriate treatment and disposal methods, including
burying, managed landfill and incineration.
•• Manage waste management sites to prevent or minimise protection risks,
especially for children.
6.
6 Minimise packing material and reduce the solid waste burden by working
with organisations responsible for food and household item distribution.
Key indicator
There is no solid waste accumulating around designated neighbourhood or

communal public collection points
Guidance notes
People on the move will discard items that are heavy or no longer needed. Solid
waste generation at distribution points may increase tensions with host popula
tions. The volume of solid waste will increase if distributed household items do
not meet real needs. This solid waste is likely to be of different materials to that
generated locally and may need to be treated or disposed of differently.
Urban areas: Urban solid waste management infrastructure may be integrated
with other service systems. Work with existing authorities and systems to accom
modate the extra solid waste burden.
Protection for waste handlers: Provide protective clothing for everyone involved
in solid waste management. At a minimum, provide gloves. Ideally, also provide
boots and protective masks. When necessary, provide immunisation against
tetanus and hepatitis B. Ensure soap and water is available for washing hands
and face. Inform and train staff on the correct ways to transport and dispose of
127
waste and of the risks associated with improper management ⊕ see Essential
healthcare – communicable diseases standard 2.1.1: Prevention.
Waste handlers can be stigmatised as dirty or poor. Community consultation can
help to change attitudes. Ensuring waste handlers have appropriate equipment
and are able to maintain cleanliness will also help.
Communal settlements and rural areas: Household solid waste disposal may be
possible, and even preferred, in communal settlements and areas with lower
population densities. Base the size of domestic solid waste burial or burning pits
on household size and an assessment of the waste stream. Household pits should
be properly fenced to prevent children and animals accessing them, and ideally be
located at least 15 metres from dwellings.
For neighbourhood or communal collection points, initially provide a 100-litre
container for every 40 households. Provide one container per ten households in
the longer term, as household waste production is likely to increase over time. As a
guide, a 2.5-person maintenance team should be available per 1,000 persons.
Reuse, re-purpose and recycle: Encourage reuse, re-purposing or recycling of
solid waste by the community, unless doing so presents a significant public
health risk. Consider the potential for small-scale business opportunities or
supplementary income from waste recycling, and the possibility of household
or communal composting of organic waste.

Household and personal actions to safely manage
solid waste
People can safely collect and potentially treat solid waste in their households.
Key actions
1.
1 Provide households with convenient, adequately sized and covered storage
for household waste or containers for small clusters of households.
•• Consider household preference for the number and size of containers for
reuse and recycling.
2.
2 Provide clearly marked and fenced public neighbourhood collection points
where households can deposit waste on a daily basis.
3.
3 Organise a system to regularly remove household and other waste from
designated public collection points.
4.
4 Ensure that solid waste burial or burning pits at household or communal
levels are safely managed.
128
Key indicators
Percentage of households with access to a designated neighbourhood or
communal solid waste collection point at an acceptable distance from their
dwelling
Percentage of households reporting appropriate and adequate waste storage at

household level
Guidance note
Planning: The amount of solid waste that people generate depends on how food
is obtained and cooked, and which activities are carried out within or near the
household. Variations can be seasonal and often reflect distribution or market
schedules. Assume that one person generates 0.5 kilograms of solid waste per
day. This equates to 1–3 litres per person per day, based on a typical solid waste
density of 200 to 400kg/m3.

Solid waste management systems at community level
Designated public collection points do not overflow with waste, and final
treatment or disposal of waste is safe and secure.
Key actions
1.
1 Ensure that institutions such as schools and learning spaces, child-
friendly spaces and administrative offices have clearly marked, appro
priate and adequate covered on-site storage for waste generated at
that location.
2.
2 Provide clearly marked and fenced storage for waste generated in
communal areas, especially formal or informal marketplaces, transit
centres and registration centres.
Key indicators
Percentage of schools and learning centres with appropriate and adequate
waste storage
Percentage of public markets with appropriate and adequate waste storage
Percentage of solid waste pits or incinerators at schools, learning centres,

public markets and other public institutions that are managed safely
129
Guidance notes
Market waste: Marketplaces need particular attention, as communal areas
often lack designated ownership and responsibility for solid waste management.
Treat most market waste in the same manner as domestic solid waste.
Abattoir waste: Ensure that slaughtering is hygienic and complies with local laws.
Much of the solid waste produced by abattoirs and fish markets can be treated as
domestic solid waste but pay special attention to their liquid waste. If appropriate,
dispose of this waste in a covered pit next to the abattoir or fish processing plant.
Run blood and other liquid waste into the pit through a slab-covered channel to
reduce insect access to the pit. Make water available for cleaning purposes.
130
WASH IN DISEASE OUTBREAKS AND HEALTHCARE SETTINGS
6. WASH in disease outbreaks

and healthcare settings
WASH and health actors both work to reduce public health risks, prevent disease
transmission and control disease outbreaks. Strong coordination with government
structures and partners – across the two sectors – is needed to address public
health risks in the community and in healthcare settings. This standard builds on
WASH standards 1–5 and the Health chapter, which should be consulted in their
entirety and guide all technical interventions.
Infection prevention and control (IPC) is a key activity in disease prevention in
any situation as well as for outbreak response. It is critical for the patient, the
healthcare worker and the community. It is the responsibility of health agencies
to ensure Minimum Standards are met in healthcare settings, but doing so often
requires structured collaboration and support from WASH actors.
Good and consistently applied WASH practices, in both the community and
healthcare settings, will reduce transmission of infectious diseases and help
control outbreaks. Minimum actions in this standard apply to ongoing response
and highlight areas to scale up in the event of an outbreak.
Community-based outbreak response

It is not always practical to respond to every component of WASH. Focus on the
immediate public health risk and build trust and accountability with the commu
nities. Prioritise response based on epidemiological findings, assessment of risk
factors, transmission routes (especially beyond faecal–oral), expected impact of
each intervention and available resources.
Community engagement remains a key component of outbreak response in order
to prevent the spread of disease. Existing community perceptions and beliefs can
support or hinder a response, so it is important to understand and address them.
Some social norms may need to be modified to prevent disease transmission.
For example, work with the community to find alternative forms of greeting to
replace handshaking.
Encourage specific disease prevention and treatment measures within the
affected community. This can include using mosquito nets to prevent malaria,
or oral rehydration salts and zinc (for children) for diarrhoea.
If community outreach workers perform active case finding or related tasks, they
must be trained. Integrate all data into the overall outbreak investigation and
response. Quick tracking of the spread of the outbreak and who it affects is critical
for a timely response, and integrated data in a common system will prevent
double counting or missing key areas ⊕ see Essential healthcare – communicable
diseases standard 2.1.4: Outbreak preparedness and response.
131
During any disease outbreak always follow up-to-date technical guidance, as

emerging diseases will have different risks and impact. Extensive guidance
exists on IPC in specific disease prevention and control, and this must be followed
as a priority ⊕ see References below. This standard provides a minimum of issues to
be considered and describes the collaboration between WASH and health sectors.
The diagram below provides an overview of key community-based WASH actions
during an outbreak. For health actions, ⊕ see Essential healthcare – communicable
diseases standards 2.1.1 to 2.1.4.
WASH principles for

action in the community
during outbreaks
Develop and utilise Define and agree
inter-sectoral outbreak monitoring and reporting
preparedness and framework, with indicators
response plan specific to the outbreak
Priority interventions
Safe control Safe excreta

of key vectors containment,
Rapid action with transport and
effect as quickly as possible. treatment
Ensure that quick-fix actions
honour quality, speed and
appropriateness
Risk-focused Safe and

community adequate water
engagement and quality and
hygiene promotion quantity
Safe collection,
transport and disposal
of solid waste
Defined and agreed roles

Continuously access public
and responsibilities (within
health data to inform and
and between sectors)
Promote early health adapt programme design
seeking behaviour at
healthcare facilities
WASH principles for action in the community during outbreaks (Figure 5)
132
Standard 6:
WASH in healthcare settings
All healthcare settings maintain minimum WASH infection prevention and
control standards, including in disease outbreaks.
Key actions
1.
1 Provide a reliable water supply of sufficient quantity and quality, appropriate
to the healthcare setting.
•• Store at least 48 hours’ worth of safe water (0.5mg/l free residual chlorine)
to ensure a constant supply.
•• Outbreaks: Increase water quantities and adapt chlorine solutions according
to disease type, risk and needs.
2.
2 Provide sufficient excreta disposal facilities to limit disease transmission.
•• Provide commode chairs and bucket toilets for those facing mobility
barriers.
•• Clean sanitation facilities (toilets, showers, washing area) with water and
detergent. Avoid using strong detergents in toilets.
•• Outbreaks: Provide excreta disposal facilities in each zone of the healthcare
setting.
•• Outbreaks: Adapt materials and supplies for the specific disease, such as
cholera beds and excreta or vomit buckets.
•• Outbreaks: Determine any extra precautions needed for cleaning,
decommissioning and desludging excreta facilities and equipment.
3.
3 Provide enough cleaning materials and equipment for healthcare workers,
patients and visitors to maintain hygiene.
•• Provide handwashing stations at key locations with safe water, soap or
alcohol rub. Air dry or use “once only” towels.
•• Outbreaks: Provide handwashing stations in each zone.
•• Outbreaks: Set up additional hygiene practices, such as chlorine foot baths
or spraying (depending on the disease) and handwashing before putting on or
removing personal protective equipment (PPE).
•• Outbreaks: Provide patients with specific hygiene items and training before
discharge.
4.
4 Maintain a clean and hygienic environment.
•• Clean floors and horizontal work surfaces daily with water and detergent.
•• Clean and disinfect potentially contaminated surfaces with a 0.2 per cent
chlorine solution.
•• Clean, disinfect or sterilise reusable medical devices depending on risk before
each use.
133
•• Disinfect all linen with 0.1 per cent chlorine solution after soaking if visibly
soiled; sterilise all linens for operating theatres.
•• Outbreaks: Increase disinfectant strengths for cleaning floors and contami
nated surfaces. Consider special mechanisms for disinfecting linen.
5.
5 Handle, treat and dispose of waste correctly.
•• Segregate healthcare waste at point of generation using the three-bin method.

•• Train all healthcare workers in waste segregation and management.
•• Ensure that designated teams should wear PPE to collect, treat and dispose
of waste (minimum: gloves and boots).
•• Outbreaks: Increase waste-handling precautions, using full PPE based on
disease type.
6.
6 Ensure all healthcare workers, patients and carers use appropriate PPE.
•• Provide PPE for the type of exposure and category of isolation precautions.
•• Train healthcare workers, patients and others in the facility to select, use and
remove PPE.
•• Outbreaks: Assess the type of anticipated exposure and adapt PPE to type
of transmission.
7.
7 Manage and bury the dead in a way that is dignified, culturally appropriate
and safe according to public health practices.
•• Consider local traditions as well as the need for identification and return of
deceased to families.
•• Outbreaks: Identify alternatives with the community if usual practices are unsafe.
•• Outbreaks: Train and equip teams with appropriate PPE to carry out burials.
Key indicators
All healthcare workers clean their hands, using soap or alcohol rub, before and
after every patient contact
All patients and carers wash their hands before handling or eating food and
after going to the toilet
All handwashing stations have soap or alcohol rub (or 0.05 per cent chlorine
solution in outbreaks)
Number of handwashing stations

•• Minimum: one station for every ten inpatients
Drinking water quality at point of delivery

•• Minimum: 0.5–1mg/l FRC
Quantity of safe water available

•• Minimum: 5 litres per outpatient per day
134
•• Minimum: 60 litres per patient per day in cholera treatment centre

•• Minimum: 300–400 litres per patient per day in viral haemorrhagic fever
treatment centre
Number of accessible toilets

•• Minimum: four in outpatient facilities (separated for men, women, children
and healthcare workers)
•• Minimum: 1 per 20 inpatients (separated for men, women, children and
healthcare workers)
Guidance notes
Infection prevention and control programming is essential in all healthcare settings,
including ambulances and community health programmes. It requires develop
ment of guidelines on standard precautions, transmission-based precautions and
clinical aseptic techniques. Include a dedicated infection prevention and control
team in each setting and training for healthcare workers. Surveillance systems
should monitor healthcare-associated infections and antimicrobial resistance.
Settings should have appropriate staffing and workload. Beds should contain one
patient only. Healthcare should be provided in a safe and appropriate environment,
built with sufficient WASH infrastructure and equipment to maintain safe hygiene
practices ⊕ see Health systems standards 1.1 and 1.2.
Water quantity and quality: When calculating amounts of water required, refer to
the values in Appendix 3 and adjust for the situation, ⊕ see Appendix 3: Minimum
water quantities. Mobile clinics should aim to provide the same WASH standards
as for outpatients, including access to a safe water source and toilets. Ensure
at least a 48-hour supply (and storage) per facility. For outbreaks such as Ebola
and cholera, allow for 72 hours’ supply. For the foundations of community WASH
programmes ⊕ see Water supply standards 2.1 and 2.2.
The following chlorine solutions are required for different uses in healthcare
settings.
Chlorine solution Healthcare facility activity

0.05% Handwashing
Laundry (after cleaning)
0.2% (cholera) Wiping horizontal work surfaces after cleaning (for cholera only)
0.5% (Ebola) Cleaning materials, aprons, boots, cooking utensils and dishes
Rinsing bedpans, buckets
Cleaning surfaces contaminated with body fluid
Preparing dead bodies (Ebola)
2% Preparing dead bodies (cholera)
Added to excreta and vomit buckets (cholera)
1% Mother solution for chlorinating water
135
Excreta management: ⊕ See Excreta management standards 3.1 to 3.3 for guidance
on excreta management generally and Hygiene promotion standard 1.3: Menstrual
hygiene management and incontinence for specific information on materials.
Provide technically and culturally appropriate toilet facilities with separate
locked and well-lit toilets with sufficient space for carers to assist patients.
All sanitation facilities (toilets, showers, washing area) should be cleaned with
water and detergent. Avoid using strong disinfectants inside toilets (particu
larly for septic tanks), as it disrupts the natural biodegradation processes of
some pathogens.
During outbreaks, take extra precautions when cleaning, decommissioning or
desludging excreta facilities and equipment (for example, chlorine solution for
cleaning, treatment with quicklime or chlorine).
Greywater: As a minimum dispose of greywater using a grease trap and
soakaway pit. Ensure it is fenced off to prevent tampering by the public.
Healthcare waste contains infectious organisms such as HIV and hepatitis B,
which can also contaminate soil and water sources. Use a minimum three-bin
method to collect and segregate waste as soon as it is created:
Category Example Container colour/label

General waste Paper Black
Not hazardous
Used sharps Needles, scalpels, infusion sets, Yellow, labelled “SHARPS”, leak-
Hazardous, infectious broken glass, empty vials proof and puncture-proof
Not sharps Materials contaminated with body Yellow, labelled and leak-proof
Hazardous, infectious fluids, such as swabs, dressings,
sutures, laboratory cultures
Further segregation may be needed, including for pathological (human tissue),

pharmaceutical and chemical (laboratory reagents) waste. Collect segregated
waste from the medical area at least daily, and immediately if highly infectious. Use
trolleys to transport waste using a fixed route to designated areas with restricted
public access. Waste containers, trolleys and storage areas must be disinfected
regularly. Vaccinate all healthcare waste handlers for hepatitis B and tetanus.
Treat and dispose of waste depending on the available facilities:
Category Treatment and disposal

General Recycle, burn, or bury
Municipal landfill
Used sharps Sharps pit
Encapsulate and bury in landfill
Incinerate (not vials) then bury in ash pit (with caution, as
sharps may not be blunted)
136
Category Treatment and disposal

Infectious Burial pit (cover waste with quicklime)
(not sharps) Incinerate then bury in ash pit
Autoclave or chemically treat
Pathological Depends on socio-cultural norms:
Burial pits (for example, placenta pit) or burial sites
Cremation
Pharmaceutical Follow national guidelines if possible or return to supplier
Encapsulate and dispose in landfill
Special incinerators (>1,200 degrees Celsius)
Chemical waste Follow national guidelines if possible or return to supplier
Small amounts can be incinerated or encapsulated
Treat in treatment plant or rotary kiln
Incinerators should exceed 900 degrees Celsius and have dual chambers.
Low-quality incinerators produce toxic emissions and air pollutants and do
not completely sterilise. All pits and incinerators should be built to existing
national and international standards and be safely operated, maintained and
decommissioned.
Personal protective equipment (PPE) is mandatory for compliance with IPC
protocols and to ensure that patients, families and staff are not put at further risk.
Assess the type of exposure anticipated (splash, spray, contact or touch) and the
disease transmission category. Use equipment that is well-fitted, durable and
appropriate (such as fluid-resistant or fluid-proof).
Basic PPE protects wearers from exposure to blood, body fluid, secretions or
excretions. It includes: gloves when touching infectious material; gowns/aprons
when clothes or exposed skin is in contact with infectious material; face protection
such as masks, goggles or shields to protect from splashes, droplets or sprays.
Additional PPE (or basic PPE at additional times) may also have to be worn
depending on type of disease transmission: contact (e.g. gown and gloves when
in patient environment); droplet (surgical masks within 1 metre of patient); and
airborne (particulate respirators).
Place single-use PPE in waste bins (such as 220-litre barrels) at the entrance to
the undressing area. Collect and take bins to a designated waste management
area. Place reusable PPE such as heavy-duty gloves and goggles in bins containing
a 0.5 per cent chlorine solution. Clean, launder, repair and store appropriately.
A 0.5 per cent chlorine solution should be available for washing gloved hands after
each undressing step. Provide a separate 0.05 per cent chlorine solution hand
washing stand as the final step in the undressing process.
Management of the dead: Promote safe, dignified and culturally appropri
ate burial of dead persons, including identification of all persons. Let people
identify their family members and conduct funerals. Do not dispose of bodies
137
unceremoniously in mass graves. Mass burial may be a barrier to obtaining the

death certificates necessary for making legal claims. Consider potential legal
issues when burying the victims of violence ⊕ see Health systems standard 1.1:
Health service delivery.
Special precautions, such as preparing the dead with chlorine solution, may be
needed during outbreaks, depending on the disease pathogen and its transmis
sion. Rituals for cleansing and caring for the dead can increase the possibility of
disease transmission, but failure to respect cultural sensitivities could lead to
burials happening in secret and being unreported.
Healthcare workers and burial teams should wear PPE at all times. Support
community burial workers with psychosocial services. Work with community
leaders to prevent stigmatisation of people performing this role.
Decommissioning: Consult the community, local authorities and humanitarian
actors to decide how to decommission a temporary healthcare setting during
a response.
138
Appendix 1 – Water supply, sanitation and hygiene promotion initial needs assessment checklist
Appendix 1
Water supply, sanitation and hygiene promotion
initial needs assessment checklist
This list of questions is primarily for use to assess needs, identify resources
and describe local conditions. It does not include questions that will determine
the external resources needed to supplement those immediately and locally
available.
General
•• How many people are affected and where are they? Disaggregate the data
by sex, age, disability and so on.
•• What are people’s likely movements? What are the security factors for the
affected people and for potential relief responses?
•• What are the current, prevalent or possible WASH-related diseases?
•• Who are the key people to consult or contact?
•• Who are the vulnerable people in the population and why?
•• Is there equal access for all to existing facilities, including at public places,
health centres and schools?
•• What special security risks exist for women, girls, boys and men? At-risk
groups?
•• What water, sanitation and hygiene practices were the population accus
tomed to before the crisis?
•• What are the formal and informal power structures (for example, community
leaders, elders, women’s groups)?
•• How are decisions made in households and in the community?
•• Is there access to local markets? What key WASH goods and services
were accessible in the market before the crisis and are accessible during
the crisis?
•• Do people have access to cash and/or credit?
•• Are there seasonal variations to be aware of that may restrict access or
increase demands on labour during harvesting time, for example?
•• Who are the key authorities to liaise and collaborate with?
•• Who are the local partners in the geographical area, such as civil society
groups that have similar capacity in WASH and community engagement?
Hygiene promotion
•• What water, sanitation and hygiene practices were people accustomed to
before the crisis?
•• What existing practices are harmful to health, who practises these and why?
139
•• Who still practises positive hygiene behaviour and what enables and
motivates them to do this?
•• What are the advantages and disadvantages of any proposed changes in
practice?
•• What are the existing formal and informal channels of communication and
outreach (such as community health workers, traditional birth attendants,
traditional healers, clubs, cooperatives, churches and mosques)?
•• What access to the mass media is there in the area (for example, radio,
television, video, newspapers)?
•• What local media organisations and/or non-governmental organisations
(NGOs) are there?
•• Which segments of the population can and should be targeted (for example,
mothers, children, community leaders, religious leaders)?
•• What type of outreach system would work in this context (for example,
community hygiene volunteers or workers or promoters, school health
clubs, WASH committees) for both immediate and medium-term
mobilisation?
•• What are the learning needs of hygiene promotion staff and community
outreach workers?
•• What non-food items are available and what are the most urgently needed
based on preferences and needs?
•• Where do people access markets to buy their essential hygiene items? Has
this access (cost, diversity, quality) changed since the crisis?
•• How do households access their essential hygiene items? Who makes the
decisions regarding which items to buy and prioritise?
•• How effective are hygiene practices in healthcare settings (particularly
important in epidemic situations)?
•• What are the needs and preferences of women and girls for menstrual
hygiene practices?
•• What are the needs and preferences of people living with incontinence?
Water supply
•• What is the current water supply source and who are the present users?
•• How much water is available per person per day?
•• What is the daily and weekly frequency of the water supply availability?
•• Is the water available at the source sufficient for short-term and longer-term
needs for all groups?
•• Are water collection points close enough to where people live?
Are they safe?
•• Is the current water supply reliable? How long will it last?
•• Do people have enough water containers of the appropriate size and type
(collection and storage)?
•• Is the water source contaminated or at risk of contamination
(microbiological, chemical or radiological)?
140
•• Is there a water treatment system in place? Is treatment necessary?

Is treatment possible? What treatment is necessary?
•• Is disinfection necessary? Does the community have problems with water
palatability and acceptance associated with chlorine taste and smell?
•• Are there alternative sources of water nearby?
•• What traditional beliefs and practices relate to the collection, storage and
use of water?
•• Are there any obstacles to using the available water supply sources?
•• Is it possible to move the population if water sources are inadequate?
•• What are the alternatives if water sources are inadequate?
•• Are there any traditional beliefs and practices related to hygiene
(for example, during the Haiti cholera outbreak the disease was
associated with voodoo culture)? Are any of these beliefs or practices
either useful or harmful?
•• What are the key hygiene issues related to water supply?
•• Do people buy water? If so where, at what cost and for what purposes?
Has this access (the cost, quality, regularity of delivery) changed?
•• Do people have the means to use water hygienically?
•• Are waterpoints and laundry and bathing areas well drained?
•• Are soil conditions suitable for on-site or off-site management of
problem water from waterpoints and laundry and bathing areas?
Has a soil percolation test been carried out?
•• In the event of rural displacement, what is the usual source of water
for livestock?
•• Will there be any environmental effects due to possible water supply
intervention, abstraction and use of water sources?
•• What other users are currently using the water sources? Is there a risk of
conflict if the sources are utilised for new populations?
•• What opportunities are there to collaborate with the private and/or public
sector in water provision? What bottlenecks and opportunities exist that
could inform the response analysis and recommendations?
•• What operation and maintenance duties are necessary? What capacity is
there to fulfil them in the short and long term? Who shall be accountable
for them?
•• Is there an existing or potential finance mechanism or system that can
recover the operation and maintenance costs?
•• How does the host population access water and ensure that its water is safe
at the point of use?
Excreta disposal
•• Is the environment free of faeces?
•• If there is open defecation, is there a designated area?
•• Are there any existing facilities? If so, are they used? Are they sufficient?
Are they operating successfully? Can they be extended or adapted?
141
•• Are the facilities safe and dignified: lighted, equipped with locks, privacy
screens? Can people access the toilet facilities during the day and night?
If not at night, what are the alternatives?
•• What excreta management practices does the host population practice?
•• Is the current defecation practice a threat to water supplies (surface or
groundwater) or living areas and to the environment in general?
•• Are there any social – cultural norms to consider in the design of the toilet?
•• Are people familiar with the design, construction and use of toilets?
•• What local materials are available for constructing toilets?
•• Is there an existing acceptance of and practice for composting?
•• From what age do children start to use the toilet?
•• What happens to the faeces of infants and young children?
•• What is the slope of the terrain?
•• What is the level of the groundwater table?
•• Are soil conditions suitable for on-site excreta disposal?
•• Do current excreta disposal arrangements encourage vectors?
•• Are there materials or water available for anal cleansing? How do people
normally dispose of these materials?
•• Do people wash their hands after defecation and before food preparation
and eating? Are soaps or other cleansing materials with water available next
to the toilet or within the household?
•• How do women and girls manage menstruation? Are there appropriate
materials or facilities available for this?
•• Are there any specific facilities or equipment available for making sanitation
accessible for persons with disabilities, people living with HIV, people living
with incontinence or people immobile in medical facilities?
•• Have environmental considerations been assessed: for example, the
extraction of raw materials such as sand and gravel for construction
purposes, and the protection of the environment from faecal matter?
•• Are there skilled workers in the community, such as masons or carpenters
and unskilled labourers?
•• Are there available pit emptiers or desludging trucks? Currently, is the
collected faecal waste disposed of appropriately and safely?
•• What is the appropriate strategy for management of excreta – inclusive of
containment, emptying, treatment and disposal?
Vector-borne diseases
•• What are the vector-borne disease risks and how serious are they?
•• What daily or seasonal patterns do local vectors follow in relation to
reproduction, resting and feeding?
•• Are there traditional beliefs and practices (for example, the belief that
dirty water causes malaria) that relate to vectors and vector-borne
disease? Are any of these beliefs or practices either useful or harmful?
142
•• If vector-borne disease risks are high, do people at risk have access to

individual protection?
•• Is it possible to make changes to the local environment (especially by, for
example, drainage, scrub clearance, excreta disposal, solid waste disposal) to
inhibit vector breeding?
•• Is it necessary to control vectors by chemical means? What programmes,
regulations and resources exist regarding the use of chemicals for vector
control?
•• What information and safety precautions need to be provided to
households?

•• Is accumulated solid waste a problem?
•• How do people dispose of their waste? What type and quantity of solid
waste is produced?
•• Can solid waste be disposed of on-site or does it need to be collected and
disposed of off-site?
•• What is the normal solid waste disposal practice for affected people
(for example, compost and/or refuse pits, collection system, bins)?
•• Are there medical facilities and activities producing waste? How is it
disposed of? Who is responsible?
•• Where are disposable sanitary materials disposed of (for example, children’s
nappies, menstruation hygiene materials and incontinence materials)? Is
their disposal discreet and effective?
•• What is the effect of the current solid waste disposal on the environment?
•• What solid waste management capacity do the private and public
sectors have?
143
Appendix 2
The F diagram: faecal–oral transmission
of diarrhoeal diseases
Barriers can stop the transmission of disease; these
WATER
can be primary (preventing the initial contact with the
faeces) or secondary (preventing it being ingested by a
SANITATION
new person). They can be controlled by water,
sanitation and hygiene interventions.
HYGIENE
Protect the FLUIDS Treat, transport and

water source store the water safely
Separate faeces
from the
environment
Wash hands
Wash hands FINGERS before eating or
after defaecation preparing food
Store and
FOOD cook food
carefully
FAECES Cover food

FACES
FLIES
Separate faeces Wash hands

from the Control flies
environment
Wash hands
before eating or
preparing food
Peel and wash

FIELDS food
FLOODS
Drainage
Primary barrier Secondary barrier
NOTE The diagram is a summary of pathways; other associated routes may be important. Drinking water may be contaminated
by a dirty water container, for example, or food may be infected by dirty cooking utensils. © WEDC
The 5 Fs: faeces, fluids, fingers, flies, food (Figure 6)

Source: Water, Engineering and Development Centre (WEDC)
144
Appendix 3 – Minimum water quantities
Appendix 3
Minimum water quantities: survival figures
and quantifying water needs
Surviving needs: water intake 2.5–3 litres per person per day (depends on climate and
(drinking and food) individual physiology)
Basic hygiene practices 2–6 litres per person per day (depends on social and
cultural norms)
Basic cooking needs 3–6 litres per person per day (depends on food type,
social and cultural norms)
Health centres and hospitals 5 litres per outpatient
40–60 litres per in-patient per day
100 litres per surgical intervention and delivery
Additional quantities may be needed for laundry
equipment, flushing toilets and so on
Cholera centres 60 litres per patient per day
15 litres per carer per day
Viral haemorrhagic fever centre 300–400 litres per patient per day
Therapeutic feeding centres 30 litres per in-patient per day
15 litres per carer per day
Mobile clinic with infrequent visits 1 litre per patient per day
Mobile clinic with frequent visits 5 litres per patient per day
Oral rehydration points (ORPs) 10 litres per patient per day
Reception/transit centres 15 litres per person per day if stay is more than one day
3 litres per person per day if stay is limited to day-time
Schools 3 litres per pupil per day for drinking and hand washing
(Use for toilets not included: see Public toilets below)
Mosques 2–5 litres per person per day for washing and drinking
Public toilets 1–2 litres per user per day for hand washing
2–8 litres per cubicle per day for toilet cleaning
All flushing toilets 20–40 litres per user per day for conventional flushing
toilets connected to a sewer
3–5 litres per user per day for pour-flush toilets
Anal washing 1–2 litres per person per day
Livestock 20–30 litres per large or medium animal per day
5 litres per small animal per day
145
Appendix 4
Minimum numbers of toilets:
community, public places and institutions
Location Short term Medium and long term

Community 1 toilet for 50 persons 1 toilet for 20 persons (shared family)
(communal) 1 toilet for 5 persons or 1 family
Market areas 1 toilet for 50 stalls 1 toilet for 20 stalls
Hospitals/medical 1 toilet for 20 beds or 1 toilet for 10 beds or
centres 50 outpatients 20 outpatients
Feeding centres 1 toilet for 50 adults 1 toilet for 20 adults
1 toilet for 20 children 1 toilet for 10 children
Reception/transit 1 toilet for 50 individuals
centres 3:1 female for male
Schools 1 toilet for 30 girls 1 toilet for 30 girls
1 toilet for 60 boys 1 toilet for 60 boys
Offices 1 toilet for 20 staff
Source: Adapted from Harvey, Baghri and Reed (2002)
Note: Where the context allows, aim for shared family toilets or, even better, household toilets from the onset
in order to build acceptance, ownership and culturally appropriate sanitation interventions.
Note: the community, the same number of bathing facilities as toilets per 50 persons (short-term) or
20 persons (long-term) should be provided.
146
Appendix 5 – Water- and sanitation-related diseases
Appendix 5
Water- and sanitation-related diseases
1 . Environmental classification of water-related infections
Category Infection Pathogenic agent
1) F
aecal–oral (water-borne
or water-washed)
a) Diarrhoeas and dysenteries Amoebic dysentery Protozoon
Balantidiasis Protozoon
Campylobacter enteritis Bacterium
Cholera Bacterium
Cryptosporidiosis Protozoon
E. coli diarrhoea Bacterium
Giardiasis Protozoon
Rotavirus diarrhoea Virus
Salmonellosis Bacterium
Shigellosis Bacterium
Yersiniosis Bacterium
b) Enteric fevers Typhoid Bacterium
Paratyphoid Bacterium
Poliomyelitis Virus
Hepatitis A Virus
Leptospirosis Spirochaete
Ascariasis Helminth
Trichuriasis Helminth
2) Water-washed
a) Skin and eye infections Infectious skin diseases Miscellaneous
Infectious eye diseases Miscellaneous
b) Other Louse-borne typhus Rickettsia
Louse-borne relapsing fever Spirochaete
3) Water-based
a) Penetrating skin Schistosomiasis Helminth
b) Ingested Guinea worm Helminth
Clonorchiasis Helminth
Diphyllobothriasis Helminth
Paragonimiasis Helminth
Others Helminth
4) Water-related insect vector
a) Biting near water Sleeping sickness Protozoon
b) Breeding in water Filariasis Helminth
Malaria Protozoon
River blindness Helminth
Mosquito-borne viruses Virus
Yellow fever Virus
Dengue Virus
Others
Source: ACF: Water, Sanitation and Hygiene for Populations at Risk, Annex 5, page 675
147
2. Environmental classification of excreta-related infections

Category Infection Pathogenic Dominant Major control meas-
agent transmission ure (engineering
mechanisms measures in italics)
1) Faecal–oral Poliomyelitis Virus Person to Domestic water
(non-bacterial) Hepatitis A Virus person contact supply
Non-latent, low Rotavirus diarrhoea Virus Domestic Improved housing
infection dose Amoebic dysentery Protozoon contamination Provision of toilets
Giardiasis Protozoon Health education
Balantidiasis Protozoon
Enterobiasis Helminth
Hymenolepiasis Helminth
2) Faecal–oral Diarrhoeas and Person to Domestic water
(bacterial) dysenteries person contact supply
Non-latent, Campylobacter Bacterium Domestic Improved housing
medium, or high enteritis contamination Provision of toilets
infectious dose Cholera Bacterium Water Excreta treatment
Moderately per- E. coli diarrhoea Bacterium contamination before reuse or
sistent and able Salmonellosis Bacterium Crop discharge
to multiply Shigellosis Bacterium contamination Health education
Yersiniosis Bacterium
Enteric fevers
Typhoid Bacterium
Paratyphoid Bacterium
3) Soil-transmitted Ascariasis Helminth Yard Provision of toilets
helminths (roundworm) contamination with clean floors
Latent and Trichuriasis Helminth Ground Excreta treatment
persistent with (whipworm) contamination before land
no intermediate Hookworm Helminth in communal application
host Strongyloidiasis Helminth defaecation area
Crop
contamination
4) Beef and pork Taeniasis Helminth Yard Provision of toilets
tapeworms contamination Excreta treatment
Latent and per- Field before land
sistent with cow contamination application
or pig intermedi- Fodder Cooking and meat
ate host contamination inspection
5) Water-based Schistosomiasis Helminth Water Provision of toilets
helminths Clonorchiasis Helminth contamination Excreta treatment
Latent and Diphyllobothriasis Helminth before discharge
persistent with Paragonimiasis Helminth Control of animals
aquatic interme- harbouring infection
diate host(s) Cooking
148
Appendix 5 – Water- and sanitation-related diseases
Category Infection Pathogenic Dominant Major control meas-

agent transmission ure (engineering
mechanisms measures in italics)
6) Excreta-related Filariasis (trans Helminth Insects breed in Identification and
insect vectors mitted by Culex various faecally elimination of
pipiens mosquitoes) contaminated potential breeding
infections sites sites
Infections in catego Use of mosquito
ries 1–4, especially I Miscellaneous netting
and II, which may be
transmitted by flies
and cockroaches
149
Appendix 6
Household water treatment and storage
decision tree
Is the source contaminated?
Provide safe
YES NO water storage
and handling
Are commercial water treatment products being

used in the humanitarian response?
NO YES
Pre-treatment: Is the
Is the water muddy?
water muddy or cloudy?
NO YES NO YES
Promote Promote flocculation /

straining, settling disinfection;
and decanting, or promote simple
three pot method, filtration, settling and
or simple filters decanting or three pot
with frequent method, followed by
cleaning double dose of
chlorine. Also promote
safe water storage
and handling
Disinfection: Is wood or another

heat source readily available? Is the water cloudy?
NO YES NO YES
Promote solar Promote boiling Promote filtration Promote filtration

disinfection. and safe water (biosand, colloidal (biosand, colloidal
Also promote safe storage and silver ceramic silver ceramic
water storage and handling. Also membrane filters, membrane filters,
handling promote etc) or use a etc) or use a
responsible wood double dose double dose
collection and of chemical of chemical
reforestation disinfection. disinfection.
Also promote safe Also promote safe
water storage water storage
and handling and handling
Source: Adapted from IFRC (2008) Household water treatment and safe storage in emergencies manual
150

General/right to water
The Rights to Water and Sanitation (Information Portal). www.righttowater.info
United Nations General Assembly Resolution 64/292 The human right to water and
sanitation. 2010. www.un.org
Impact of WASH on health

Bartram, J. Cairncross, S. “Hygiene, sanitation, and water: forgotten foundations of
health.” PLoS Med, vol. 7, 2010, e1000367.
Blanchet, K. et al. An Evidence Review of Research on Health Interventions in
Humanitarian Crises. LSHTM, Harvard School of Public Health, 2013. www.elrha.org
Campbell, O.M. Benova, L. et al. “Getting the basic rights: the role of water, sanitation
and hygiene in maternal and reproductive health: a conceptual framework.” Trop Med Int
Health, vol. 20, 2015, pp. 252-67.
Fewtrell, L. Kaufmann, et al. “Water, sanitation, and hygiene interventions to reduce
diarrhoea in less developed countries: a systematic review and meta-analysis.” Lancet
Infectious Diseases, vol. 5, 2005, pp. 42-52. www.thelancet.com
Ramesh, A. Blanchet, K. et al. “Evidence on the Effectiveness of Water, Sanitation, and
Hygiene (WASH) Interventions on Health Outcomes in Humanitarian Crises: A Systematic
Review.” PLoS One, vol. 10, 2015, e0124688.
Wolf, J. Pruss-Ustun, A. et al. “Assessing the impact of drinking water and sanitation
on diarrhoeal disease in low- and middle-income settings: systematic review and meta-
regression.” Trop Med Int Health, vol. 19, no. 9, 2014.
Effective WASH programming

Compendium of accessible WASH technologies. WaterAid and WEDC, 2014.
www.wateraid.org
Davis, J. Lambert, R. Engineering in Emergencies (2nd ed). ITDG Publishing & RedR
UK, 2002.
Efficacy and effectiveness of water, sanitation, and hygiene interventions in emergencies in
low- and middle-income countries: a systematic review.
https://www.developmentbookshelf.com
Public Health Engineering in Precarious Situations. MSF, 2010.
http://refbooks.msf.org
WASH Manual for Refugee Settings: Practical Guidance for Refugee Settings. UNHCR,
2017. http://wash.unhcr.org
Water, Sanitation and Hygiene for Populations at Risk. ACF, 2005.
www.actionagainsthunger.org
151
Protection and WASH

House, S. Ferron, S. Sommer, M. Cavill, S. Violence, Gender & WASH: A Practitioner’s
Toolkit - Making water, sanitation and hygiene safer through improved programming and
services. WaterAid/SHARE, 2014. http://violence-WASH.lboro.ac
Humanitarian Inclusion Standards for older people and people with disabilities. Age and
Disability Consortium, 2018. https://www.cbm.org
INEE Minimum Standards for Education: Preparedness, Response, Recovery. INEE,
2010.www.inees ite.org
Jones, H.E. Reed, R. Water and sanitation for disabled people and other vulnerable
groups: Designing services to improve accessibility. Loughborough University, UK,
2005. wedc-knowledge.lboro.ac
Minimum Standards for Child Protection in Humanitarian Action: Alliance for Child
Protection in Humanitarian Action, 2012. http://cpwg.net
Hygiene promotion/behaviour change

Curtis, V. Cairncross, S. “Effect of washing hands with soap on diarrhoea risk in the
community: a systematic review.” Lancet Infect Dis, vol. 3, 2003, pp. 275-81.
De Buck, E. Hannes, K. et al. Promoting handwashing and sanitation behaviour change in
low- and middle income countries. A mixed method systematic review. Systematic Review
36. International Initiative for Impact Evaluation, June 2017. www.3ieimpact.org
Ferron, S. Morgan, J. O’Reilly, M. Hygiene Promotion: A Practical Manual from Relief to
Development. ITDG Publishing, Rugby, UK, 2000 and 2007.
Freeman, M.C. Stocks, M.E. et al. “Hygiene and health: systematic review of hand-
washing practices worldwide and update of health effects.” Trop Med Int Health, vol. 19,
2014, pp. 906-16.
Harvey, P. Baghri, S. Reed, B. Emergency Sanitation: Assessment and Programme
Design. WEDC, 2002. https://wedc-knowledge.lboro.ac
Hygiene Promotion in Emergencies. Training package. WASH Cluster.
http://washcluster.net
Hygiene Promotion Guidelines. UNHCR, 2017. http://wash.unhcr.org
Rabie, T. Curtis, V. “Handwashing and risk of respiratory infections: a quantitative
systematic review.” Trop Med Int Health, vol. 11, 2006, pp. 258-67.
Watson, J.A. Ensink, J.H. Ramos, M. Benelli, P. Holdsworth, E. Dreibelbis, R.
Cumming, O. “Does targeting children with hygiene promotion messages work? The
effect of handwashing promotion targeted at children, on diarrhoea, soil-transmitted
helminth infections and behaviour change, in low- and middle-income countries.” Trop
Med Int Health, 2017.
Menstrual hygiene
Mahon, T. Cavill, S. Menstrual Hygiene Matters: Training guide for practitioners. WaterAid.
https://washmatters.wateraid.org
Sommer, M. Schmitt, M. Clatworthy, D. A Toolkit for integrating Menstrual Hygiene
Management (MHM) into Humanitarian Response. Colombia University, Mailman
152
School of Public Health and International Rescue Committee. New York, 2017.
www.rescue.org
Incontinence
Groce, N. Bailey, N. Land, R. Trani, J.F. Kett, M. “Water and sanitation issues for persons
with disabilities in low- and middle-income countries: a literature review and discussion
of implications for global health and international development.” Journal of Water and
Health, vol. 9, 2011, pp. 617-27.
Hafskjold, B. Pop-Stefanija, B. et al. “Taking stock: Incompetent at incontinence - why
are we ignoring the needs of incontinence sufferers?” Waterlines, vol. 35, no. 3, 2016.
www.developmentbookshelf.com
Excreta management
Clasen, T.F. Bostoen, K. Schmidt, W.P. Boisson, S. Fung, I.C. Jenkins, M.W. Scott, B.
Sugden, S. Cairncross, S. “Interventions to improve disposal of human excreta for
preventing diarrhoea.” Cochrane Database Syst Rev, 2010, CD007180.
Freeman, M.C. Garn, J.V. Sclar, G.D. Boisson, S. Medlicott, K. Alexander, K.T.
Penakalapati, G. Anderson, D. Mahtani, A.G. Grimes, J.E.T. Rehfuess, E.A. Clasen, T.F.
“The impact of sanitation on infectious disease and nutritional status: A systematic
review and meta-analysis.” Int J Hyg Environ Health, vol. 220, 2017, pp. 928-49.
Gensch, R. Jennings, A. Renggli, S. Reymond, Ph. Compendium of Sanitation
Technologies in Emergencies. German WASH Network and Swiss Federal Institute of
Aquatic Science and Technology (Eawag), Berlin, Germany, 2018.
Graham, J.P. Polizzotto, M.L. “Pit latrines and their impacts on groundwater quality:
A systematic review.” Environmental Health Perspectives, vol. 121, 2013.
http://hsrc.himmelfarb.gwu
Harvey, P., Excreta Disposal in Emergencies: A Field Manual. An Inter-Agency
Publication, WEDC, 2007. http://wash.unhcr.org
Simple Pit Latrines. WASH Fact sheet 3.4. WHO. www.who.int
Water treatment
Branz, A. Levine, M. Lehmann, L. Bastable, A. Imran Ali, S. Kadir, K. Yates, T. Bloom,
D. Lantagne, D. “Chlorination of drinking water in emergencies: a review of knowledge
to develop recommendations for implementation and research needed.” Waterlines,
vol. 36, no. 1, 2017. https://www.developmentbookshelf.com
Lantagne, D.S. Clasen, T.F. “Point-of-use water treatment in emergencies.” Waterlines,
vol. 31, no. 1-2, 2012.
Lantagne, D.S. Clasen, T.F. “Use of household water treatment and safe storage
methods in acute emergency response: Case study results from Nepal, Indonesia,
Kenya, and Haiti.” Environmental Science and Technology, vol. 46, no. 20, 2012.
Rayner, J. Murray, A. Joseph, M. Branz, A.J. Lantagne, D. “Evaluation of household
drinking water filter distributions in Haiti.” Journal of Water, Sanitation and Hygiene for
Development, vol. 6, no. 1, 2016.
153
Water quality
Bain, R. Cronk, R. Wright, J. Yang, H. Slaymaker, T. Bartram, J. “Fecal Contamination
of Drinking-Water in Low- and Middle-Income Countries: A Systematic Review and Meta-
Analysis.” PLoS Med, vol. 11, 2014, e1001644.
Guidelines for Drinking-Water Quality. WHO, 2017. www.who.int
Kostyla, C. Bain, R. Cronk, R. Bartram, J. “Seasonal variation of fecal contamination
in drinking water sources in developing countries: a systematic review.” PubMed, 2015.
Vector control
Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. New Edition.
World Health Organization, Geneva, 2009. Chapter 3, Vector management and
delivery of vector control services. www.who.int
Handbook for Integrated Vector Management. WHO, 2012. www.who.int
Lacarin, C.J. Reed, R.A. Emergency Vector Control Using Chemicals. WEDC,
Loughborough University, 1999. UK. https://wedc-knowledge.lboro.ac
Malaria Control in Humanitarian Emergencies: An Inter-agency Field Handbook. WHO,
2005. www.who.int
Thomson, M. Disease Prevention Through Vector Control: Guidelines for Relief
Organisations. Oxfam GB, 1995. https://policy-practice.oxfam.org
Vector Control: Aedes aegypti vector control and prevention measures in the context of
Zika, Yellow Fever, Dengue or Chikungunya: Technical Guidance. WASH WCA Regional
Group, 2016. http://washcluster.ne

Disaster Waste Management Guidelines. UNOCHA, MSB and UNEP, 2013.
www.eecentre.org
Technical Notes for WASH in Emergencies, no. 7: Solid waste management in emergencies.
WHO/WEDC, 2013. www.who.int
WASH in disease outbreaks

Brown, J. Cavill, S. Cumming, O. Jeandron, A. “Water, sanitation, and hygiene
in emergencies: summary review and recommendations for further research.”
Waterlines, vol. 31, 2012.
Cholera Toolkit. UNICEF, 2017. www.unicef.org
Essential environmental health standards in health care. WHO, 2008.
http://apps.who.int
Guide to Community Engagement in WASH: A practitioners guide based on lessons from
Ebola. Oxfam, 2016. https://policy-practice.oxfam.org
Infection prevention and control (IPC) guidance summary: Ebola guidance package. WHO,
2014. www.who.int
Lantagne, D. Bastable, A. Ensink, J. Mintz, E. “Innovative WASH Interventions to
Prevent Cholera.” WHO Wkly Epid Rec. October 2, 2015.
154
Management of a Cholera Epidemic. MSF, 2017. https://sherlog.msf.org

Rapid Guidance on the Decommissioning of Ebola Care Facilities. WHO, 2015.
Taylor, D.L. Kahawita, T.M. Cairncross, S. Ensink, J.H. “The Impact of Water, Sanitation
and Hygiene Interventions to Control Cholera: A Systematic Review.” PLoS One, vol. 10,
e0135676. Doi: 10.1371/journal.pone.0135676, 2015. http://journals.plos.org
Yates, T. Allen, J. Leandre Joseph, M. Lantagne, D. WASH interventions in disease
outbreak response. Humanitarian Evidence Programme. Oxfam GB, 2017.
https://policy-practice.oxfam.org
Yates, T. Vujcic, J.A. Joseph, M.L. Gallandat, K. Lantagne, D. “Water, sanitation, and
hygiene interventions in outbreak response: a synthesis of evidence.” Waterlines,
vol. 37, no. 1, pp. 5–30. https://www.developmentbookshelf.com
Infection prevention and control

Aide Memoire for infection prevention and control in a healthcare facility. WHO, 2011.
http://www.who.int
Essential water and sanitation requirements for health structures. MSF, 2009.
Guidelines on Core Components of Infection Prevention and Control Programmes at the
National and Acute Health Care Facility Level. WHO, 2016. www.who.int
Guidelines for Safe Disposal of Unwanted Pharmaceuticals in and after Emergencies.
WHO, 1999. www.who.int
Hand Hygiene Self-Assessment Framework. WHO, 2010. www.who.int
Incineration in Health Structures of Low-Income Countries. MSF, 2012.
https://sherlog.msf.org
Laundries for Newbies. MSF, 2016. https://sherlog.msf.org
Management of Dead Bodies after Disasters: A Field Manual for First Responders.
Second Edition. ICRC, IFRC, 2016. https://www.icrc.org
Medical Waste Management. ICRC, 2011. https://www.icrc.org
Safe management of wastes from health-care activities. Second edition. WHO, 2014.
www.who.int
Sterilisation Guidelines. ICRC, 2014. http://icrcndresourcecentre.org
WASH in health care facilities. UNICEF, WHO, 2015. www.who.int
Waste Zone Operators Manual. MSF, 2012. https://sherlog.msf.org
WASH and nutrition

Altmann, M. et al. “Effectiveness of a household water, sanitation and hygiene package
on an outpatient program for severe acute malnutrition: A pragmatic cluster - randomized
controlled trial in Chad.” The American Journal of Tropical Medicine and Hygiene, vol. 98,
no. 4, Apr 2018, pp. 1005-12. https://www.ajtmh.org
BABYWASH and the 1,000 days: a practical package for stunting reduction. Action
Against Hunger (ACF), 2017. https://www.actionagainsthunger.org
155
Null, C. et al. (2018) “Effects of water quality, sanitation, handwashing, and

nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster
randomised control trial.” The Lancet: Global Health, vol. 6, no. 3, March 2018,
pp. e316-e329. https://www.sciencedirect.com
Oxfam and Tufts University WASH and Nutrition Series: Enteric Pathogens and
Malnutrition. Technical memorandum 1. Oxfam, Tufts.
https://oxfamintermon.s3.amazonaws.com
WASH’NUTRITION 2017 Guidebook: Integrating water, sanitation, hygiene and nutrition
to save lives. Action Against Hunger (ACF), 2017. www.actionagainsthunger.org
WASH, cash and markets

CaLP CBA quality toolbox. http://pqtoolbox.cashlearning.org
Further reading
156
further reading
Further reading
General/Right to water
2.1 billion people lack safe drinking water at home, more than twice as many lack
safe sanitation. WHO, 2017. www.who.int/mediacentre/news/releases/2017/
water-sanitation-hygiene/en/
The Right to Water: Fact Sheet 35. OHCHR, UN-HABITAT and WHO, 2010. www.
ohchr.org/Documents/Publications/FactSheet35en.pdf
General/Environment
Environment Marker – Guidance Note. UN OCHA & UNEP, 2014. www.humanitari
anresponse.info/sites/www.humanitarianresponse.info/files/documents/files/
Environment%20Marker%2BGuidance%20Note_Global_2014-05-09.pdf
Effective WASH programming

Disaster risk reduction and water, sanitation and hygiene: comprehensive guidance: a
guideline for field practitioners planning and implementing WASH interventions. www.
preventionweb.net/publications/view/25105
WASH and protection

Including children with disabilities in humanitarian action. WASH Booklet. UNICEF,
2017. http://training.unicef.org/disability/emergencies/index.html
WASH, Protection and Accountability, Briefing Paper. UNHCR, 2017.
WASH, Protection and Accountability Briefing Paper. UNHCR, 2017. http://wash.unhcr.
org/download/wash-protection-and-accountability/
Hygiene promotion/behaviour change

ABC – Assisting Behaviour Change Part 1: Theories and Models and Part 2: Practical
Ideas and Techniques. ACF France. 2013.
Choose Soap Toolkit. London School of Hygiene and Tropical Medicine (LSHTM),
2013.
Communication for Behavioural Impact (COMBI) A toolkit for behavioural and social
communication in outbreak response. WHO, 2012. www.who.int/ihr/publications/
combi_toolkit_outbreaks/en/
Curtis, V. Schmidt, W. et al. “Hygiene: new hopes, new horizons.” Lancet Infect Dis,
vol. 11, 2011, pp. 312-21.
Guidelines on Hygiene Promotion in Emergencies. IFRC, 2017. www.ifrc.org/en/
what-we-do/health/water-sanitation-and-hygiene-promotion/hygiene-
promotion/
Harvey, P. Baghri, S. Reed, B. Emergency Sanitation: Assessment and Programme
Design. WEDC, 2002. https://wedc-knowledge.lboro.ac.uk/details.html?id=16676
F1
or http://www.unicefinemergencies.com/downloads/eresource/docs/WASH/
Emergency%20Sanitation%20(WEDC).pdf
Kittle, B. A Practical Guide to Conducting a Barrier Analysis. Helen Keller International,
New York, 2013. http://pdf.usaid.gov/pdf_docs/PA00JMZW.pdf
Service, O. et al (The Behavioural Insights Team) EAST: Four Simple Ways to Apply
Behavioural Insights. In partnership with Cabinet Office, Nesta, 2014. www.
behaviouralinsights.co.uk/publications/east-four-simple-ways-to-apply-
behavioural-insights/
Menstrual hygiene
House, S. Considerations for selecting sanitary protection and incontinence materials
for refugee contexts. UNHCR Publication, 2016. http://wash.unhcr.org/download/
considerations-for-selecting-sanitary-protection-and-incontinence-materials-
for-refugee-contexts/
House, S. Mahon, T. Cavill, S. Menstrual Hygiene Matters; A resource for improving
menstrual hygiene around the world. WaterAid/SHARE, 2012. https://washmatters.
water aid.or g /sites/g /f iles/jk xoof 256/f iles/Mens t r ual% 20 hygiene% 20
matters%20low%20resolution.pdf
Excreta management
Majorin, F. Torondel, B. Ka Saan Chan, G. Clasen, T.F. “Interventions to improve disposal
of child faeces for preventing diarrhoea and soil-transmitted helminth infection.” Cochrane
Database of Systematic Reviews, 2014.
Simple Pit Latrines. WASH Fact sheet 3.4. WHO. www.who.int/water_sanitation_
health/hygiene/emergencies/fs3_4.pdf
Water quality
Fewtrell, L. “Drinking water nitrate, methemoglobinemia, and global burden of disease:
A discussion.” Environ Health Perspectives, vol. 112, no. 14, Oct 2004, pp. 1371-74.
doi: 10.1289/ehp.7216. www.ncbi.nlm.nih.gov/pmc/articles/PMC1247562/
Kostyla, C. Bain, R. Cronk, R. Bartram, J. “Seasonal variation of fecal contamination in
drinking water sources in developing countries: A systematic review.” Science of The Total
Environment, vol. 514, 2015, pp. 333-43.
Villenueava, C.M. et al. “Assessing Exposure and Health Consequences of Chemicals
in Drinking Water: Current State of Knowledge and Research Needs.” Environmental
Health Perspectives, vol. 122, 2014, pp. 213-21. pdfs.semanticscholar.org/
d037/3e8020adfaa27c45f43834b158cea3ada484.pdf
Vector control
Benelli, G. Jeffries, C.L. Walker, T. “Biological Control of Mosquito Vectors:
Past, Present, and Future.” Insects, vol. 7, no. 4, 2016. www.ncbi.nlm.nih.gov/
pubmed/27706105
Chemical methods for the control of vectors and pests of public health importance.
WHO, 1997. http://apps.who.int/iris/handle/10665/63504
F2
further reading
Hunter, P. Waterborne Disease: Epidemiology and Ecology. John Wiley & Sons
Ltd, Chichester, UK, 1997. www.wiley.com/en-us/Waterborne+Disease%3A+
Epidemiology+and+Ecology-p-9780471966463
Malaria Control in Humanitarian Emergencies. Working Group GFATM in Humanitarian
Emergencies, 2009. www.unhcr.org/4afacdfd9.pdf
Manual for Indoor Residual Spraying: Application of Residual Sprays for Vector Control,
3rd Ed. WHO, 2007. http://apps.who.int/iris/handle/10665/69664
Malaria vector control policy recommendations and their applicability to product
evaluation. WHO, 2017. www.who.int/malaria/publications/atoz/vector-control-
recommendations/en/
Rozendaal, J.A. Vector Control: Methods for use by individuals and communities. WHO,
1997. www.who.int/whopes/resources/vector_rozendaal/en/
Warrell, D. Gilles, H. (eds). Essential Malariology. Fourth Edition. Arnold. London, 2002.
WASH in disease outbreaks

Cholera Outbreak Guidelines: Preparedness, Prevention and Control. Oxfam, 2012.
https://policy-practice.oxfam.org.uk/publications/cholera-outbreak-guidelines-
preparedness-prevention-and-control-237172
Ebola: Key questions and answers concerning water, sanitation and hygiene. WHO/
UNICEF, 2014. http://apps.who.int/iris/bitstream/10665/144730/1/WHO_EVD_
WSH_14.2_eng.pdf
Schiavo, R. Leung, M.M. Brown, M. “Communicating risk and promoting disease
mitigation measures in epidemics and emerging disease settings.” Pathog Glob Health,
vol. 108, no. 2, 2014, pp. 76–94. www.ncbi.nlm.nih.gov/pubmed/24649867
WASH and nutrition

Dodos, J. Mattern, B. Lapegue, J. Altmann, M. Ait Aissa, M. “Relationship between
water, sanitation, hygiene and nutrition: what do Link NVA nutritional causal analyses
say?” Waterlines, vol. 36, no. 4, 2017. https://www.developmentbookshelf.com/doi/
abs/10.3362/1756-3488.17-00005
Luby, S. et al. (2018) “Effects of water quality, sanitation, handwashing, and nutritional
interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised
control trial.” The Lancet: Global Health, vol. 6, no. 3, March 2018, pp. e302-e315.
https://www.sciencedirect.com/science/article/pii/S2214109X17304904
WASH, cash and markets

Cash and Markets in the WASH Sector: A Global WASH Cluster position paper. Global
WASH Cluster, 2016. www.emma-toolkit.org/sites/default/files/bundle/GWC%20
-%20Cash%20and%20Markets%20Position%20Paper%20-%20Dec%202016.pdf
Cash Based Interventions for WASH Programmes in Refugee Settings. UNHCR, 2014.
www.unhcr.org/59fc35bd7.pdf
F3
Food Security
and Nutrition
Humanitarian
Charter
Protection Core
Standard
Management Micro- Infant and

Food Food
Assessments of nutrient young child Livelihoods
security assistance
malnutrition deficiencies feeding
Standard 1.1 Standard 2.1 Standard 3 Standard 4.1 Standard 5 Standard 6.1 Standard 7.1
Food Moderate Micronutrient Policy General General Primary

security acute deficiencies guidance and food nutrition production
assessment malnutrition coordination security requirements
Standard 1.2 Standard 2.2 Standard 4.2 Standard 6.2 Standard 7.2
Nutrition Severe Multi-sectoral Food quality, Income and

assessment acute support to appropri- employment
malnutrition infant and ateness and
young child acceptability
feeding in
emergencies
Standard 6.3
Targeting,
distribution
and delivery
Standard 6.4
Food use
Appendix 1 Food security and livelihoods assessment checklist

Appendix 2 Seed security assessment checklist
Appendix 3 Nutrition assessment checklist
Appendix 4 Measuring acute malnutrition
Appendix 5 Measures of the public health significance of micronutrient deficiencies
Appendix 6 Nutritional requirements
158
Contents
Essential concepts in food security and nutrition.......................................................... 160
1. Food security and nutrition assessments.................................................................... 165
2. Management of malnutrition............................................................................................ 172
3. Micronutrient deficiencies................................................................................................. 182
4. Infant and young child feeding......................................................................................... 185
5. Food security.......................................................................................................................... 193
6. Food assistance..................................................................................................................... 197
7. Livelihoods............................................................................................................................... 211
Appendix 1: Food security and livelihoods assessment checklist........................... 219
Appendix 2: Seed security assessment checklist...........................................................221
Appendix 3: Nutrition assessment checklist....................................................................223
Appendix 4: Measuring acute malnutrition......................................................................225
Appendix 5: Measures of the public health significance of micronutrient
deficiencies..........................................................................................................228
Appendix 6: Nutritional requirements................................................................................231
159
Essential concepts
in food security and nutrition
Everyone has the right to be free from hunger and to have adequate food
The Sphere Minimum Standards for food security and nutrition are a practical
expression of the right to adequate food in humanitarian contexts. The standards
are grounded in the beliefs, principles, duties and rights declared in the
Humanitarian Charter. These include the right to life with dignity, the right to
protection and security, and the right to receive humanitarian assistance on
the basis of need.
Charter, with explanatory comments for humanitarian workers, ⊕ see Annex 1.
Undernutrition reduces people’s ability to recover after a crisis. It impairs cognitive
functions, reduces immunity to disease, increases susceptibility to chronic
illness, limits livelihoods opportunities and reduces the ability to engage within
the community. It undermines resilience and may increase dependence on
ongoing support.
The causes of undernutrition are complex

The immediate causes of undernutrition are inadequate food intake and repeated
disease ⊕ see Figure 7. The underlying causes are household food insecurity, poor
feeding and care practices, unhealthy household environment and inadequate
healthcare.
These underlying causes are inter-connected. So, although food insecurity is one
cause of undernutrition, providing food assistance is unlikely to lead to a lasting
solution unless other causes are addressed at the same time. Food and nutrition
responses should work with WASH, shelter and settlement, and healthcare
responses in a coordinated approach. For example, people require an adequate
quantity and quality of water to prepare nutritious food and to adopt safe feeding
practices. Having access to sanitation and hygiene facilities will reduce the risk of
disease outbreaks. Having access to adequate shelter provides access to cooking
facilities and protects people from extreme weather, which further reduces the
risk of disease. When people have access to good healthcare, they are likely to have
a higher nutritional status. This in turn increases their ability to pursue livelihood
opportunities.
Control of the underlying causes will prevent and reduce undernutrition. Retaining
people’s livelihood assets is fundamental to this, because it increases their ability
to manage other potential causes of undernutrition. Livelihoods assets include
equipment and machinery, raw materials, land, knowledge and access to functioning
markets. Food security and nutrition responses should contribute to protecting
160
Essential concepts in food security and nutrition
SHORT-TERM LONG-TERM
CONSEQUENCES CONSEQUENCES
Morbidity, Adult size, intellectual
mortality, disability MATERNAL ability, economic
productivity, reproductive
AND CHILD performance, metabolic
UNDERNUTRITION and cardiovascular disease
Inadequate
Disease
dietary intake
IMMEDIATE
CAUSES
Unhealthy Inadequate maternal

Household
household intake, poor infant and
food insecurity,
environment and young child feeding and
access, availability,
inadequate impaired care practices
consumption
health services
POOR LIVELIHOOD STRATEGIES

INCOME POVERTY
Employment, self-employment, dwelling,
UNDERLYING assets, remittances, pensions, transfers
CAUSES
INSUFFICIENT
LIVELIHOOD ASSETS
Financial, human, physical, social,
BASIC natural and political
CAUSES
Shocks, trends, seasonality, social, economic, cultural and political environment
Food security and nutrition: causes of undernutrition (Figure 7)
161
and developing these assets, and therefore supporting different livelihood strategies,
whether there are high malnutrition rates or not.
Social, economic, cultural and political changes in the post-crisis environment
will affect a household’s coping strategies and access to livelihoods or live-
lihood assets. Stabilising those external factors will contribute to increased
opportunities for income and ultimately reduce people’s exposure to the causes
of undernutrition.
Working in urban areas brings specific challenges

Increasing urbanisation is creating new challenges for the food security and
nutrition sector. Urban environments potentially offer increased employment
and income-generating opportunities. However, as urban populations increase,
demand for housing and services in those areas also increases. In many cases,
existing land use planning policies and strategies cannot meet the unanticipated
demand. Overcrowding, air pollution, poor waste management and lack of sani-
tation facilities in slums increase the chance of contracting acute illnesses. This
reduces people’s ability to take advantage of livelihoods opportunities and often
triggers the underlying causes of undernutrition.
Some groups are particularly vulnerable to undernutrition

Developing an appropriate food response requires a full understanding of the
unique nutritional needs of pregnant and breastfeeding women, infants and
children, older people and persons with disabilities. Improving food security at
the household level also requires an understanding of different roles. Women,
for instance, often play a greater role in the planning and preparation of food for
their households.
It is important to disaggregate data by sex, age and disability at a minimum. This
shows who needs what kind of food and who may be missing important nutritional
elements. Disaggregate post-distribution monitoring in the same way, to confirm
that programme interventions are providing equitable access to adequate and
appropriate food and nutrition.
Preventing undernutrition is just as important as treating acute malnutrition. Food
security and nutrition interventions may determine nutrition and health status in
the short term, and survival and well-being in the long term.

The Minimum Standards in this chapter reflect the core content of the right to food
and contribute to the progressive realisation of this right globally.
The right to adequate food is linked to the rights to water and sanitation, health,
and shelter. Progress in achieving the Sphere Minimum Standards in one area
influences progress in other areas. Therefore, an effective response requires
close coordination and collaboration with other sectors, local authorities and
other responding agencies. This helps ensure that needs are met, that efforts
162
Essential concepts in food security and nutrition
are not duplicated and that the quality of food security and nutrition responses
is optimised. Cross-references throughout the Handbook suggest potential
linkages.
For example, if nutritional requirements are not being met, the need for WASH is
greater, because people’s vulnerability to disease increases. The same applies to
populations where HIV is prevalent or where there is a large proportion of older
people or persons with disabilities. In those circumstances, healthcare resources
will also need to be adjusted. Decide priorities based on information shared
between sectors, and review it as the situation evolves.
Where national standards are lower than the Sphere Minimum Standards,
humanitarian organisations should work with the government to raise them
progressively.
International law specifically protects the right to adequate food

The right to be free from hunger and to have adequate food is protected by inter-
national law. It requires physical and economic access to adequate food at all
times. States are obliged to ensure this right when individuals or groups, including
refugees and internally displaced persons, are unable to access adequate food,
including in crises ⊕ see Annex 1.
States may request international assistance if their own resources are insufficient.
In doing so they should:
•• respect existing access to adequate food, and allow continued access;
•• protect individuals’ access to adequate food by ensuring that organisations
or individuals do not deprive them of such access; and
•• actively support people to ensure secure livelihoods and food security by
providing them with the resources they need.
Withholding adequate food from civilians as a method of warfare is prohibited
under the Geneva Conventions. It is also prohibited to attack, destroy, remove or
render useless crops, livestock, foodstuffs, irrigation works, drinking water instal-
lations and supplies, and agricultural areas that produce foodstuffs.
In the case of occupation, international humanitarian law obliges an occupying
power to ensure adequate food for the population, including importing supplies if
those in the occupied territory are inadequate.
Links to the Protection Principles and Core Humanitarian Standard

Food and nutrition assistance has the potential to lead to serious rights violations
if it is misused, particularly in exploitation or abuse of programme participants.
Programmes must be designed with the affected population and implemented in
ways that contribute to their safety, dignity and integrity. Proper management and
strong oversight of staff and resources are required, along with strict adherence
and enforcement of a code of conduct for all those involved in delivering assistance
programmes. Establish clear feedback mechanisms with the affected population
163
and respond quickly to any concerns. Aid workers should be trained on child safe-
guarding and know how to use referral systems for suspected cases of violence,
abuse or exploitation, including of children ⊕ see Protection Principle 1 and Core
Humanitarian Standard Commitment 5.
Civil-military cooperation and coordination, such as logistical support, should be
carefully evaluated in all situations, and especially in conflict settings ⊕ see What is
Sphere and Protection Principles.
In applying the Minimum Standards, all nine Commitments in the Core Humanitarian
Standard should be respected as a foundation for providing an accountable food
security and nutrition programme.
164
Food security and nutrition assessments
1. Food security and nutrition

assessments
Food security and nutrition assessments are required throughout a crisis. They
show how the context evolves and enable responses to be adjusted appropriately.
Ideally food security and nutrition assessments should overlap, as they identify
the barriers to adequate nutrition and to the availability, access to and use of food.
Joint food security and nutrition assessments can increase cost-effectiveness and
link nutrition to food security programming.
Assessments should adhere to widely accepted principles, use internationally
accepted methods, and be impartial, representative and well-coordinated
between humanitarian organisations and governments. Assessments must be
complementary, consistent and comparable. Stakeholders must agree on a
suitable methodology. It should include a cross-section of the affected population,
with attention given to at-risk groups. Multi-sectoral assessments can help in
assessing large-scale crises and wide geographical areas.
The objective of food security and nutrition assessments can be to:
•• understand the situation, current needs and how to meet those needs;
•• estimate how many people need assistance;
•• identify groups at highest risk; and/or
•• provide a baseline to monitor the impact of a humanitarian response.
The assessments can be conducted at various stages of a crisis. For example:
•• an initial assessment within the first two to three days to start immediate
distribution of food assistance;
•• a rapid assessment within two to three weeks, relying on assumptions and
estimates to provide a basis for designing programmes;
•• a detailed assessment within 3 to 12 months if the situation seems to
be deteriorating or more information is required to develop recovery
programmes.
Detailed food security assessments identify livelihood strategies, assets and

coping strategies. They consider how these have changed as a result of the crisis,
and the consequences for household food security. A detailed assessment should
identify how best to protect and/or promote these livelihood strategies in order to
achieve food security.
Detailed nutrition assessments involve collecting and analysing representative
data to establish prevalence rates of acute malnutrition, infant and young child
feeding, and other care practices. This data, combined with analysis of the other
underlying causes of malnutrition, and assessments of health and food security,
165
presents a nutrition causal analysis. This is useful in planning, implementing and

monitoring nutrition programmes.
Markets play a crucial role in food security and nutrition in both urban and rural
environments. All assessments should include an analysis of markets that
meets the Minimum Standard for Market Analysis (MISMA) and/or the Minimum
Economic Recovery Standard (MERS) Assessment and Analysis standards ⊕ see
Delivering assistance through markets.
The following food security and nutrition assessment standards build on Core
Humanitarian Standard Commitment 1 to design appropriate food security and
nutrition responses for the affected people ⊕ see Appendices 1, 2 and 3 and the LEGS
Handbook for assessment checklists.
Food security and nutrition assessments standard 1.1:

Food security assessment
Where people are at risk of food insecurity, assessments are conducted to
determine the degree and extent of food insecurity, identify those most
affected and define the most appropriate response.
Key actions
1.
1 Collect and analyse information on food security at the initial stage and
during the crisis.
•• Include analysis of critical issues linked to food security, such as environ-
mental degradation, security and market access.
2.
2 Analyse the impact of food security on the nutritional status of the affected
population.
•• Include a review of the underlying causes of undernutrition, including
inadequate care, unhealthy household environments, lack of healthcare or
access to social protection systems.
•• Collect data more frequently in urban contexts, where the situation can
change more rapidly and be more difficult to observe than in rural contexts.
3.
3 Identify possible responses that can help to save lives and protect and
promote livelihoods.
•• Include market assessments and capacities of government and other actors
to respond to needs.
4.
4 Analyse available cooking resources and methods, including the type of stove
and fuel and availability of pots and utensils.
•• Analyse how people got and stored food and cooking fuel before the crisis,
their pre-crisis income, and how they cope now.
166
•• Pay attention to the rights and protection needs of women and girls, who are
most commonly responsible for fuel collection and food preparation.
Key indicators
Standardised protocols are used to analyse food security, livelihoods and
coping strategies
Percentage of analytical reports that synthesise findings, including assess-

ment methodology and constraints encountered
Guidance notes
Pre-crisis data combined with geographical information systems data can
provide an overview of the potential impact of a crisis. However, it is unlikely to
be disaggregated sufficiently to give a clear picture in an urban situation.
Assessment sources, tools and information systems: Information sources include
crop assessments, satellite images, household assessments, focus group
discussions and interviews with key informants. Useful tools include the Food
Consumption Score, Household Dietary Diversity Score and Reduced Coping
Strategies Index for rapid measurement of household food security. There are
many local and regional food security information systems, including famine
early warning systems. Use the Integrated Food Security Phase Classification
where available and use standardised protocols to classify the severity and
causes of acute food insecurity in the areas of concern. The design of food
security programmes should be based on a clear response analysis using the
findings of assessments.
Environmental degradation can cause food insecurity, and food insecurity can lead
to environmental degradation. For example, collecting firewood and producing
traditional charcoal make it possible to cook food and generate income from its
sale. However, it can also result in deforestation. Responses should protect and
support food security while limiting negative environmental impact.
At-risk groups: Disaggregate data by sex, age, disability, wealth group and other
relevant factors. Women and men may have different complementary roles in
securing household nutritional well-being. Consult with both, separately if neces-
sary, about practices related to food security, food preparation and household
resources. Be aware that older people and people with disabilities may be excluded
in intra-household distribution of food assistance.
Include girls and boys, especially child-headed households, separated or unaccom-
panied children, children with disabilities and children living in alternative care. Be
mindful of children in different crisis contexts. During infectious disease outbreaks,
for example, include children in observation, interim care and treatment centres. In
conflict settings, include children in demobilisation centres.
167
Coping strategies: Consider the different types of coping strategy, their effective-
ness and any negative effects. Some coping strategies, such as the sale of land,
migration of whole families or deforestation, may permanently undermine future
food security. Some coping strategies used by, or forced on, women, girls and boys
may impact their health, psychological well-being and social integration. These
coping strategies include transactional or “survival” sex, marrying daughters for
bride price, women and girls eating last and least, child labour, risky migration, and
sale and trafficking of children.
Proxy measures: Food consumption reflects the energy and nutrient intake
of individuals in households. It is not practical to measure actual energy and
nutrient intake during initial assessments, so use proxy indicators. For exam-
ple the number of food groups consumed by an individual or household and the
frequency of consumption over a given period reflect dietary diversity. Changes
in the daily number of meals consumed and dietary diversity are good proxy
measures of food security, especially when correlated with a household’s socio-
economic status.
Tools for measuring food consumption patterns include the Household Dietary
Diversity Score, the Household Food Insecurity Access Scale and the Food
Consumption Score. The Household Hunger Scale is another good proxy indicator
of food insecurity. Some commonly used indicators such as the Food Consumption
Score may not adequately reflect food insecurity in an urban context. Triangulate
selected measures with coping strategy measures to understand different
constraints in accessing food.
The Food Expenditure Share and its established thresholds may be too complex to
implement in urban households. This is because several people may be in charge of
the food basket, household members consume food sourced outside of the house,
and many people may contribute to household income.
Market analysis and cost of diet: Capture information about access to markets,
financial capital, livelihoods and economic vulnerability. These elements are linked
to commodity prices, income-earning opportunities and wage rates, which affect
food security. Market systems, both formal and informal, can protect livelihoods
by supplying productive items such as seeds and tools ⊕ see Food security and nutri-
tion – livelihoods standards 7.1 and 7.2.
Include a market analysis as part of initial and subsequent context assess-
ments. Market analyses should assess whether local markets can support
nutritional needs and establish the minimum cost and affordability of foods
that meet the nutrient needs of a typical household ⊕ see Delivering assistance
through markets.
Increasingly in rural areas, and regularly in urban areas, responses are market-
based. They use vendors, market spaces, local food products and transportation
services to address the needs of affected people. It is therefore important to
understand market access for at-risk groups ⊕ see MISMA Handbook.
168
Food security and nutrition assessments standard 1.2:

Nutrition assessment
Nutrition assessments use accepted methods to identify the type, degree and
extent of undernutrition, those most at risk and the appropriate response.
Key actions
1.
1 Compile pre-crisis information and conduct initial assessments to establish
the nature and severity of the nutrition situation.
•• Assess national and local capacity to lead or support a response, as well as
other nutrition actors.
2.
2 Conduct rapid mid upper arm circumference (MUAC) screening and infant
and young child feeding in emergencies (IYCF-E) assessments to assess the
nutritional situation at the onset of the crisis.
3.
3 Identify groups that have the greatest need for nutritional support.
•• Gather information on the causes of undernutrition from primary or secondary

sources, including the community’s perceptions and opinions.
•• Engage with communities to identify at-risk groups, paying attention to age,
sex, disability, chronic illness or other factors.
4.
4 Determine an appropriate response based on an understanding of the
context and the emergency.
•• Determine whether the situation is stable or declining, reviewing trends in
nutritional status over time rather than the prevalence of malnutrition at a
specific time.
•• Consider both prevention and treatment options.
Key indicators
Standardised protocols are used to assess malnutrition and identify causes
Percentage of assessment reports that include the assessment methodology

and constraints encountered
Guidance notes
Contextual information: Information on the causes of undernutrition can be gath-
ered from primary and secondary sources, including health and nutrition profiles,
research reports, early warning information, health facility records, food security
reports and other sources. Examples include:
•• demographic health surveys;
•• multi-indicator cluster surveys;
•• national nutrition information databases;
169
•• other national health and nutrition surveys;

•• national nutrition surveillance systems;
•• admission rates and coverage in existing programmes for managing
malnutrition; and
•• HIV prevalence, incidence and mortality data, including groups at higher risk
or with higher burden ⊕ see Essential healthcare – sexual and reproductive
health standard 2.3.3: HIV.
Local institutions and communities themselves should actively contribute to

assessment, interpreting findings and planning responses wherever possible.
Rapid response: In the first phase of a crisis, decisions on general food distributions
or immediate treatment of malnutrition should be based on a rapid assessment,
initial findings and the existing capacity to respond. An in-depth analysis should be
conducted at a later stage but should not delay response in the acute phase.
Scope of analysis: In-depth assessments should be conducted where information
gaps are identified and if additional information is needed for programme design,
to measure programme outcomes or for advocacy. Determine whether popu-
lation-wide qualitative or quantitative assessments are needed to understand
anthropometric status, micronutrient status, infant and young child feeding,
maternal care practices and associated potential determinants of undernutrition.
Coordinate with health, WASH and food security sectors to design and prepare for
the assessments.
Anthropometric surveys: These are used to examine physical proportions of the
body and provide an estimate of the rates of chronic and acute malnutrition. They
can be based on random sampling or specific screening. Surveys should report
weight-for-height Z scores according to World Health Organization (WHO) stand-
ards. Use weight-for-height Z scores reported against the National Center for
Health Statistics (NCHS) reference to compare with past surveys. Include wasting
and severe wasting measured by MUAC data. The most widely accepted practice
is to assess malnutrition levels in children aged 6–59 months as a proxy for the
entire population. However, where there are other groups that face greater nutri-
tional risks, consider including them in the assessment as well ⊕ see Appendix 4:
Measuring acute malnutrition.
Establish the rates of nutrition oedema and record them separately. Report
confidence intervals for the rates of malnutrition and demonstrate survey
quality assurance. Use existing tools such as the Standardised Monitoring and
Assessment of Relief and Transitions (SMART) methodology manual, Standardised
Expanded Nutrition Survey (SENS) for Refugee Populations, Emergency Nutrition
Assessment software, or Epi Info software.
Infant and young child feeding assessments: Assess the needs and priorities for
IYCF-E and monitor the impact of humanitarian action and inaction on infant and
young child feeding practices. Pre-crisis data can be used to inform early decision-
170
making. Work with other sectors to include IYCF-E questions in other sectoral
assessments and draw on available multi-sectoral data to inform the assessment
⊕ see Appendix 3: Nutrition assessment checklist.
Include the number of available breastfeeding counsellors, trained health workers and
other support services and their capacity. For more in-depth assessment, conduct
random sampling, systematic sampling or cluster sampling. This may be through a
stand-alone IYCF-E survey or an integrated survey. However, an integrated survey may
result in limited sample size, which may reduce the representativeness of the survey.
Other indicators: Additional information can be carefully considered to inform the
overall assessment of nutritional status. This includes immunisation and nutrition
programme coverage rates, especially measles, vitamin A, iodine or other micronu-
trient deficiencies, disease morbidity and health-seeking behaviour. Crude infant and
under-5 mortality rates, with cause of death, can also be considered where available.
Interpreting levels of undernutrition: Detailed analysis of the reference population
size and density, as well as mortality and morbidity rates, is needed to decide
whether levels of undernutrition require intervention. Information is also needed
on health status, seasonal fluctuations, IYCF-E indicators, pre-crisis levels of
undernutrition, the proportion of severe acute malnutrition in relation to global
acute malnutrition, and levels of micronutrient deficiencies ⊕ see Essential health-
care standard 2.2.2: Management of newborn and childhood illness and Appendix 5:
Measures of the public health significance of micronutrient deficiencies.
A combination of complementary information systems may be the most cost-
effective way to monitor trends. Decision-making models and approaches that consider
several variables, such as food security, livelihoods, and health and nutrition may be appro-
priate ⊕ see Food security and nutrition assessments standard 1.1: Food security assessment.
171
2. Management of malnutrition
The prevention and treatment of malnutrition are both important considerations
in humanitarian crises. Chronic malnutrition can be prevented, but there is limited
evidence that it can be reversed or treated. On the other hand, acute malnutrition –
which may be triggered during a crisis – can be prevented and treated with the
right nutrition responses.
Nutrition responses are key in reducing morbidity and mortality in affected
populations. However, they require an understanding of the complex underlying
causes of malnutrition. A multi-sectoral approach is essential to addressing all
the causes and their interactions.
Management of moderate acute malnutrition: In crises, supplementary feeding is
often the primary strategy for preventing and treating moderate acute malnutrition.
Two types of supplementary feeding programmes are common: blanket supple-
mentary feeding programmes for prevention, and targeted supplementary feeding
programmes for treatment of moderate acute malnutrition and prevention of severe
acute malnutrition. The use of each depends on the levels of acute malnutrition,
vulnerable population groups and the risk of an increase in acute malnutrition.
Blanket supplementary feeding programmes are recommended where food
insecurity is high and there is a need to expand interventions beyond only
moderate acute malnutrition cases. They should be accompanied by general
food distributions targeting affected households. There are no defined impact
indicators for blanket supplementary feeding programmes, but it is important to
monitor coverage, adherence, acceptability and rations provided. The indicators
for managing moderate acute malnutrition primarily refer to targeted supple-
mentary feeding.
The main aim of a targeted supplementary feeding programme is to prevent the
moderately malnourished becoming severely malnourished and to rehabilitate
them. These types of programmes usually provide a food supplement to the general
ration for moderately malnourished individuals, pregnant and nursing mothers, and
other at-risk individuals.
Management of severe acute malnutrition: A variety of approaches are used for
therapeutic care. Community-based management of acute malnutrition is the
preferred approach where conditions allow. This includes:
•• inpatient care for people with medical complications who present with
severe acute malnutrition;
•• inpatient care for all infants under six months old who present with severe
acute malnutrition;
•• outpatient care for people with severe acute malnutrition but without
medical complications;
172
Management of malnutrition
•• community outreach; and

•• other context-specific services or programmes for individuals with moderate
acute malnutrition.
Programmes addressing severe acute malnutrition should be supported by supple-

mentary feeding programmes and community mobilisation to support outreach,
active case-finding, referral and follow-up.
Management of malnutrition standard 2.1:

Moderate acute malnutrition
Moderate acute malnutrition is prevented and managed.
Key actions
1.
1 Establish clearly defined and agreed strategies, objectives and criteria for
set-up and closure of interventions from the outset of the programme.
2.
2 Maximise access to coverage of moderate acute malnutrition interventions
through community engagement and involvement from the beginning.
•• Work with community stakeholders to identify vulnerable individuals and
households.
3.
3 Establish admission and discharge protocols, based on nationally and
internationally accepted anthropometric criteria.
•• Specify the discharge criteria when reporting performance indicators.
•• Investigate and act on causes of default and non-response, or an increase in
deaths.
4.
4 Link the management of moderate acute malnutrition to the management of
severe acute malnutrition and to existing health services.
5.
5 Provide take-home dry or suitable ready-to-use supplementary food rations
unless there is a clear rationale for on-site feeding.
•• Provide rations on a weekly or every two weeks basis. Consider household
composition and size, household food security, and the likelihood of sharing
when setting the size and composition of the ration.
•• Provide clear information on how to hygienically prepare and store supple-
mentary food, and how and when to consume it.
6.
6 Emphasise protecting, supporting and promoting breastfeeding, comple-
mentary feeding and hygiene.
•• Provide clear information on the importance of exclusive breastfeeding in
children up to six months, and continued breastfeeding for children from
6 to 24 months, for both the physical and psychological health of mother
and child.
173
•• Admit breastfeeding mothers of acutely malnourished infants under six

months to supplementary feeding programmes, independent of maternal
nutrition status.
Key indicators
Percentage of target population that can access dry ration supplementary feeding
sites within one day’s return walk (including time for treatment)
•• >90 per cent
Percentage of target population that can access on-site programmes within

one hour
•• >90 per cent
Percentage of moderate acute malnutrition (MAM) cases with access to treatment

services (coverage)
•• >50 per cent in rural areas
•• >70 per cent in urban areas
•• >90 per cent in formal camps
The proportion of discharges from targeted supplementary feeding

programmes who have died, recovered or defaulted
•• Died: <3 per cent
•• Recovered: >75 per cent
•• Defaulted: <15 per cent
Guidance notes
Programme design: Design programmes that build on and support existing health
system capacity and consider access to health facilities, the geographical spread
of the population and security. Maintain links to inpatient and outpatient thera-
peutic care, ante-natal care, malaria prevention, childhood illness and screening,
HIV and tuberculosis care, and food security programmes including food, cash or
voucher transfers.
Supplementary feeding programmes are not meant to replace the diet but to
complement it. It is key to design programmes as part of a multi-sectoral approach
with complementary services such as WASH, health, IYCF and general food distri-
bution. Assess availability of supplementary foods on national or international
markets and factor potential pipeline constraints into programme planning ⊕ see
Prevention or treatment: Adopt a blanket approach to prevent malnutrition, or a
targeted approach to treat it. The decision will depend on:
•• levels of acute malnutrition and numbers of affected people;
•• risk of increased morbidity;
174
•• risk of decreased food security;

•• population displacement and density;
•• capacity to screen and monitor the affected population using anthropometric
criteria; and
•• available resources and access to the affected people.
Targeted supplementary feeding generally requires more time and effort to screen
and monitor individuals with acute malnutrition, but it also requires fewer special-
ised food resources. A blanket approach generally requires less staff expertise but
more specialised food resources.
Effective community mobilisation: Community mobilisation and involvement will
improve people’s understanding of the programme and its likely effectiveness. Work
with the target population in deciding where to locate programme sites. Consider
at-risk groups who may face difficulties in accessing sites. Share clear and compre-
hensive information on the available support in accessible languages using multiple
information-sharing channels, including audio, visual and written forms.
Coverage refers to the number of individuals receiving treatment as a proportion of
the number of people who need treatment. Coverage can be affected by the:
•• acceptability of the programme, including location and accessibility of
programme sites;
•• security situation;
•• frequency of distributions;
•• waiting time;
•• extent of mobilisation, home visits and screening;
•• availability of male and female nutrition staff;
•• alignment of admission criteria and coverage; and
•• caregivers’ ability to identify signs of malnutrition.
Coverage assessment methodologies are costly and require specially trained staff.
If coverage surveys are not feasible, consult national guidance when deciding on
alternative methods. Use routine programme data such as screening, referrals and
admissions to estimate coverage.
There may be no need to conduct regular coverage assessments unless there have
been significant changes in the programme area, such as population movements
or a new treatment product or protocol.
Admission criteria should be consistent with national and international guidance.
Admission criteria for infants below six months and for groups whose anthropomet-
ric status is difficult to determine should include clinical and breastfeeding status
⊕ see Appendix 4: Measuring acute malnutrition and References and further reading.
Individuals who are (or are suspected to be) HIV-positive or who have tuberculosis
or another chronic illness should not be discriminated against and should have
equal access to care if they meet the admission criteria. Some individuals who
do not meet anthropometric criteria for acute malnutrition may benefit from
175
supplementary feeding. This may include, for example people living with HIV,
tuberculosis or other chronic diseases, people discharged from care but requiring
therapeutic support to avoid relapse, or persons with disabilities. Adjust
monitoring and reporting systems if such individuals do not meet anthropo-
metric criteria.
People living with HIV who do not meet admission criteria often require nutri-
tional support. Such support is better offered outside the context of treatment
for severe acute malnutrition in crises. Provide these individuals and their
families with a range of services, including community and home-based care,
tuberculosis treatment centres and prevention of mother-to-child-transmission
programmes.
Discharge criteria and monitoring: The number of discharged individuals includes
those who have recovered, died, defaulted or not recovered. Individuals referred
for complementary services, such as healthcare, have not ended the treat-
ment and will either continue treatment or return to the treatment later. Do
not include individuals transferred to other sites or who have not ended the
treatment.
If individuals join a nutrition programme after discharge from therapeutic care,
report them as a separate category to avoid biased results. If an individual develops
acute malnutrition symptoms as a result of other factors such as disability, cleft or
surgical problems, include them in programme reporting. Investigate how the
gender of the individual may influence access to treatment, treatment default,
and recovery.
Calculate discharge statistics as follows:
•• Percentage of discharges recovered = number of individuals recovered/total

number of discharged x 100
•• Percentage of discharges died = number of deaths/total number of
discharged x 100
•• Percentage of discharges defaulted = number of defaulters/total number of
discharged x 100
•• Percentage of discharges not recovered = number of individuals not recov-
ered/total number of discharged x 100
In addition to the indicators outlined above, monitoring systems should include:
•• the population’s participation;

•• acceptability of the programme (the default and coverage rate could be used
as a proxy measure of this);
•• the quantity and quality of food;
•• coverage;
•• reasons for transfers to other programmes (particularly of children whose
nutritional status deteriorates to severe acute malnutrition); and
•• number of individuals admitted and in treatment.
176
Consider external factors such as:
•• morbidity patterns;
•• levels of undernutrition in the population;
•• level of food insecurity in households and in the population;
•• complementary interventions available to the population (including general
food assistance or equivalent programmes); and
•• the capacity of existing systems for service delivery.
Links to health and other sectors: Both targeted and blanket supplementary feeding
programmes can be used as a platform for delivering complementary services.
In many situations, a blanket supplementary feeding programme for prevention
can support crisis response. For example, it can provide access to the target popu-
lation through a census registration, community screening and referral for severe
acute malnutrition and moderate acute malnutrition management. It can also
allow for child survival interventions such as:
•• anthelmintics;
•• vitamin A supplementation;
•• iron and folic acid combined with malaria screening and treatment;
•• zinc for treatment of diarrhoea; and
•• immunisations.
⊕ See Essential healthcare – communicable diseases standards 2.1.1 to 2.1.4 and

Essential healthcare – child health standards 2.2.1 and 2.2.2.
Populations with high levels of vulnerability, such as high HIV prevalence and
people with difficulties moving or feeding, may require programme adaptations
to meet their needs. This could include adjusting the quality and quantity of the
supplementary food ration ⊕ see Infant and young child feeding standard 4.1.
Management of malnutrition standard 2.2:

Severe acute malnutrition
Severe acute malnutrition is treated.
Key actions
1.
1 Establish clearly defined and agreed strategies, objectives and criteria for
set-up and closure of interventions from the outset of the programme.
•• Include adequate staffing and relevant capacity, expertise and skills.
2.
2 Include inpatient care, outpatient care, referral and community mobilisation
components in the management of severe acute malnutrition.
3.
3 Provide nutrition and healthcare according to nationally and internationally
recognised guidelines for the management of severe acute malnutrition.
177
4.
4 Establish discharge criteria that include anthropometric and other indices.
5.
5 Investigate and act on causes of default and non-response, or an increase
in deaths.
6.
6 Protect, support and promote breastfeeding, complementary feeding,
hygiene promotion, and good mother and child interaction.
•• Provide clear information on the importance of exclusive breastfeeding in
children up to six months, and continued breastfeeding for children from
6 to 24 months, for both the physical and psychological health of mother
and child.
Key indicators
Percentage of the target population less than a one day’s return walk (including
time for treatment) to the programme site
•• >90 per cent of the target population
Percentage of severe acute malnutrition (SAM) cases with access to treatment

services (coverage)
•• >50 per cent in rural areas
•• >70 per cent in urban areas
•• >90 per cent in a camp
Proportion of discharges from therapeutic care who have died, recovered or

defaulted
•• Died: <10 per cent
•• Recovered: >75 per cent
•• Defaulted: <15 per cent
Guidance notes
Programme components: Inpatient care may be provided directly or through referral.
Programmes should provide decentralised outpatient care for children with no
medical complications. Outpatient programme sites should be close to the targeted
population, to reduce the risks and costs associated with travelling with young
children, and the risk of further displacement. ⊕ See Child health standard 2.2.2:
Management of newborn and childhood illness.
Link programmes with other relevant services, such as:
•• supplementary feeding;
•• HIV and tuberculosis networks;
•• rehabilitation;
•• primary health services; and
•• food security programmes including food or cash-based assistance.
178
Coverage assessment methodologies are similar in severe acute malnutrition and

moderate acute malnutrition programmes ⊕ see Management of malnutrition standard
2.1: Moderate acute malnutrition.
Admission criteria should be consistent with national and international guidance.
Admission criteria for infants below six months and for groups whose anthropometric
status is difficult to determine, should include clinical and breastfeeding status
⊕ see Appendix 4: Measuring acute malnutrition and References and further reading.
Individuals who are (or are suspected to be) HIV-positive or who have tuberculosis
or another chronic illness should not be discriminated against and should have
equal access to care if they meet the admission criteria. Some individuals who do
not meet anthropometric criteria for acute malnutrition may benefit from supple-
mentary feeding. For example people living with HIV, tuberculosis or other chronic
diseases, people discharged from care but requiring therapeutic support to avoid
relapse, or persons with disabilities. Adjust monitoring and reporting systems if
such individuals do not meet anthropometric criteria.
People living with HIV who do not meet admission criteria often require nutri-
tional support. Such support is better offered outside the context of treatment
for severe acute malnutrition in crises. Provide these individuals and their
families with a range of services, including community and home-based care,
tuberculosis treatment centres and prevention of mother-to-child-transmission
programmes.
Discharge criteria and recovery: Discharged individuals must be free from medical
complications. In addition, they should have regained their appetite and have
achieved and maintained appropriate weight gain without nutrition-related
oedema (for example, for two consecutive weighings). Calculate mean weight gain
separately for individuals with and without nutritional oedema. Breastfeeding is
especially important for infants under six months, as well as for children aged 6 to
24 months. Non-breastfed infants will need close follow-up. Adhere to discharge
criteria in order to avoid the risks associated with premature discharge.
Guidelines for community management of acute malnutrition specify the average
length of stay for treatment and aim to shorten the recovery periods. Adhere to the
existing national guidelines when calculating the average length of stay, as these
depend on the context. HIV, tuberculosis and other chronic conditions may result in
some malnourished individuals failing to respond to treatment. Work with health
services and other social and community support services to identify longer-term
treatment options for those people ⊕ see Essential healthcare – sexual and reproductive
health standard 2.3.3: HIV.
Performance indicators for managing severe acute malnutrition: The population of
discharged individuals for severe acute malnutrition is made up of those who have
recovered, died, defaulted or not recovered ⊕ see Guidance notes for Management of
malnutrition standard 2.1: Moderate acute malnutrition.
179
Performance indicators for managing severe acute malnutrition should combine

inpatient and outpatient care outcomes without double-counting those that
transfer from one to the other. If this is not possible, adjust the interpretation of
outcome rates. For example, programmes should expect better performance when
only providing outpatient care. When only providing inpatient care, programmes
should aim for the results outlined for combined care.
Individuals who are referred to other services, such as health services, have
not ended treatment. When assessing performance of outpatient treatment,
report transfers to inpatient care in order to accurately represent programme
performance.
Performance indicators do not factor in HIV clinical complexity. HIV clinical complexity
will affect mortality rates. In these situations, interpretation of programme
performance must take this into consideration.
In addition to discharge indicators, review disaggregated data of new admissions
(sex, age, disability), number of children in treatment and coverage rates when
monitoring performance. Investigate and document the proportion and causes of
readmission, deterioration of clinical status, defaulting and failure to respond on
an ongoing basis. Adapt the definition of these to guidelines in use.
Health inputs: All severe acute malnutrition programmes should include system-
atic treatments according to national or international guidance. It is essential that
they include effective referral mechanisms for managing underlying illnesses such
as tuberculosis and HIV. In areas of high HIV prevalence, malnutrition programmes
should consider interventions that seek to avoid HIV transmission and that support
maternal and child survival. In settings where HIV infection is common (HIV prev-
alence more than 1 per cent), test children with malnutrition to establish their HIV
status and to determine their need for anti-retroviral drug treatment.
Breastfeeding support: Mothers of infant inpatients need skilled breastfeeding
support as part of nutritional rehabilitation and recovery. This is particularly
important for children below six months and for mothers with disabilities. Provide
sufficient time and resources, such as a designated private breastfeeding area, to
target skilled support and enable peer support. Breastfeeding mothers of severely
malnourished infants under six months should receive a supplementary food ration
regardless of their nutritional status. If those mothers meet the anthropometric
criteria for severe acute malnutrition, admit them for treatment.
Psychosocial support: Emotional and physical stimulation through play is impor-
tant during the rehabilitation period for children with severe acute malnutrition.
It promotes attachment and positive maternal mood. Caregivers of such children
often require social and psychosocial support to bring their children for treat-
ment. Some mothers may also need to be supported to access mental health
care services for perinatal depression. This may be achieved through mobilisation
programmes. Programmes should emphasise the importance of stimulation and
interaction in treating and preventing future disability and cognitive impairment in
180
children. Enable all caregivers of severely malnourished children to feed and care
for their children during treatment; provide them with advice, demonstrations and
health and nutrition information. Pay attention to the impact of treatment on the
caregivers and siblings to ensure adequate childcare arrangements, avoid family
separation, minimise psychosocial distress and maximise the potential treatment
adherence.
Linkage with other actors: Coordinate with child protection and gender-based
violence partners to establish referral pathways and information sharing protocols.
Train nutrition staff in how to provide supportive and confidential referrals for caregivers
of children exposed to physical, sexual or emotional violence, exploitation or abuse.
181
3. Micronutrient deficiencies
Micronutrient deficiencies are a constraint to socio-economic development in
many countries. They have a great impact on people’s health, learning ability
and productivity. These deficiencies contribute to a vicious cycle of malnutrition,
underdevelopment and poverty, affecting already underprivileged groups.
Micronutrient deficiencies are difficult to identify in many contexts. While clinical
signs of severe deficiencies may be easy to diagnose, the greater burden on the
health and survival of populations may be subclinical deficiencies. Assume that a
crisis will worsen any existing micronutrient deficiencies in a population. Address
these deficiencies using population-wide interventions and individual treatment.
There are three approaches to controlling micronutrient deficiencies:
•• Supplementation: Providing micronutrients in highly absorbable form

normally results in the fastest control of the micronutrient status of
individuals or targeted populations. Examples include supplementation
programmes targeting anaemia through iron supplementation, folic acid
supplementation in pregnant women and vitamin A supplementation in
children younger than five years.
•• Fortification: Fortifying food products with micronutrients can be an effective
strategy for controlling micronutrient deficiencies. Examples of this include
iodised salt, micronutrient powders or vitamin A fortified vegetable oil.
•• Food-based approaches: The vitamins and minerals needed to prevent
micronutrient deficiencies are present in a variety of foods. Policies and
programmes should ensure improved year-round consumption of an
adequate variety, quantity and quality of safe, micronutrient-rich foods.
While all three approaches are used in crises, the most common and widely used
is supplementation.
Micronutrient deficiencies standard 3:

Micronutrient deficiencies
Micronutrient deficiencies are corrected.
Key actions
1.
1 Collect information on the pre-crisis situation to determine the most
common micronutrient deficiencies.
2.
2 Train health staff in identifying and treating micronutrient deficiencies.
3.
3 Establish procedures to respond to micronutrient deficiency risks.
182
4.
4 Link micronutrient responses with public health responses to reduce
diseases commonly associated with crises, such as vitamin A to manage
measles and zinc to manage diarrhoea.
Key indicators
There are no cases of scurvy, pellagra, beriberi or riboflavin deficiency
•• ⊕ See Appendix 5: Measures of the public health significance of micronutrient
deficiencies for a definition of public health significance by age group and
whole population.
•• Use national or context-specific indicators where they exist.
Rates of xerophthalmia, anaemia and iodine deficiency are not of public health
significance
•• ⊕ See Appendix 5: Measures of the public health significance of micronutrient
deficiencies for a definition of public health significance by age group and
whole population.
•• Use national or context-specific indicators where they exist.
Guidance notes
Diagnosing clinical micronutrient deficiencies: Clinical micronutrient deficien-
cies should always be diagnosed by qualified medical staff. When clinical indica-
tors of these deficiencies are incorporated into health or nutritional surveillance
systems, train staff to conduct the basic assessment and refer accordingly. Case
definitions are problematic; in crises, determine them through the response to
supplementation.
Subclinical micronutrient deficiencies are those that are not severe enough to
present readily identifiable symptoms. However, they can have adverse health
outcomes. Identification requires specialised biochemical examination. An excep-
tion is anaemia, for which a basic test is available and easily undertaken in the field.
Indirect indicators can be used to assess the risk of micronutrient deficiencies
and determine when supplements or an improved dietary intake may be required.
Indirect assessment involves estimating nutrient intakes at the population level
and extrapolating deficiency risk. To do this, review available data on food access,
availability and utilisation, and assess food ration adequacy.
Prevention: Strategies for micronutritient deficiency prevention are addressed in
section 6 below (⊕ see Food assistance standard 6.1: General nutrition requirements).
Disease control is critical in preventing micronutrient deficiencies. Acute respiratory
infection, measles, parasitic infections such as malaria, and diarrhoea are examples
of diseases that deplete micronutrient stores. Preparedness for treatment will
involve developing case definitions and guidelines for treatment, and systems for
active case-finding ⊕ see Essential healthcare – child health standards 2.2.1 and 2.2.2.
183
Treatment of micronutrient deficiencies: Case-finding and treatment should occur

within the health system and within feeding programmes. Where micronutrient
deficiency rates exceed public health thresholds, blanket treatment of the population
with supplements may be appropriate. Scurvy (vitamin C deficiency), pellagra
(niacin deficiency), beriberi (thiamine deficiency) and ariboflavinosis (riboflavin
deficiency) are the most commonly observed illnesses resulting from micronu-
trient deficiencies ⊕ see Appendix 5: Measures of the public health significance of
micronutrient deficiencies.
Public health measures to control micronutrient deficiencies include:
•• providing vitamin A supplementation with vaccination for children aged

6–59 months;
•• de-worming all children aged 12–59 months;
•• adding iodised salt and other fortified commodities such as vitamin A
and D fortified vegetable oil in the food basket and providing micronutrient
powders or iodised oil supplements;
•• providing iron-containing multiple micronutrient products for children aged
6–59 months;
•• providing daily iron-containing multiple micronutrient supplements, including
folic acid, for pregnant and lactating women.
If multiple micronutrient products containing iron are not available, provide daily
iron and folic acid supplements to pregnant women and those who have given birth
in the past 45 days.
Use sex-disaggregated indirect indicators to assess the risk of micronutrient
deficiecies in the affected population and determine the need for improved
dietary intake or the use of supplements. For example, indirect indicators for
vitamin A deficiency can include low birth weight, wasting or stunting. Assess
the risk of micronutrient deficiencies in affected people and determine the need for
improved dietary intake or the use of supplements ⊕ see Food Security and Nutrition
assessment standard 1.2: Nutrition assessment.
184
Infant and young child feeding
4. Infant and young child feeding

Appropriate and timely support of infant and young child feeding in emergencies
(IYCF-E) saves lives and protects children’s nutrition, health and development.
Inappropriate infant and young child feeding practices increase vulnerability
to undernutrition, disease and death, and undermine maternal health. Crises
increase those risks. Some infants and young children are particularly vulner-
able, including:
•• low birth-weight infants;

•• separated and unaccompanied children;
•• infants and children of depressed mothers;
•• children under two years not breastfeeding;
•• those from populations with medium or high HIV prevalence;
•• children with disabilities, particularly those with feeding difficulties; and
•• infants and young children with acute malnutrition, stunting or micronutrient
deficiencies.
IYCF-E addresses actions and interventions to protect and support the nutri-
tional needs of both breastfed and non-breastfed infants and young children
aged 0–23 months. Priority interventions include:
•• breastfeeding protection and support;

•• appropriate and safe complementary feeding; and
•• management of artificial feeding for infants with no possibility to breastfeed.
Support of pregnant and breastfeeding women is central to the well-being of their

children. “Exclusive breastfeeding” means an infant receives no liquids other
than breastmilk, and no solids except for necessary micronutrient supple-
ments or medicines. It guarantees food and fluid security in infants for the first
six months and provides active immune protection. Breastfeeding ensures optimal
brain development and continues to protect the health of older infants and children,
especially in contexts where WASH conditions are lacking. Breastfeeding also
protects maternal health by delaying menstruation and protecting against
breast cancer. It promotes psychological well-being by enhancing attachment
and responsiveness.
The key actions in this section reflect the Operational Guidance on Infant and Young
Child Feeding in Emergencies (Operational Guidance). The Operational Guidance
is a product of an interagency working group whose aim is to provide concise,
practical guidance on how to ensure appropriate IYCF-E and on the International
Code of Marketing of Breastmilk Substitutes (“the Code”).
185
Infant and young child feeding standard 4.1:

Policy guidance and coordination
Policy guidance and coordination ensure safe, timely and appropriate infant
and young child feeding.
Key actions
1.
1 Establish an IYCF-E coordination authority within the crisis coordination
mechanism, and ensure collaboration across sectors.
•• Assume the government is the coordination authority, wherever possible.
2.
2 Include the specifications of the Operational Guidance in relevant national
and humanitarian organisation policy guidance on preparedness.
•• Develop guidance and a joint statement with national authorities in
situations where there is no policy.
•• Strengthen relevant national policies wherever possible.
3.
3 Support strong, harmonised, timely communication on IYCF-E at all response levels.
•• Inform humanitarian organisations, donors and media as soon as possible
about any IYCF-E policies and practices that are in place.
•• Communicate with affected people about available services, IYCF-E practices
and feedback mechanisms.
4.
4 Avoid accepting or soliciting donations of breastmilk substitutes, other liquid
milk products, feeding bottles and teats.
•• Donations that do arrive should be managed by the designated authority, in
accordance with the Operational Guidance and the Code.
•• Ensure strict targeting and use, procurement, management and distribution
of breastmilk substitutes. This must be based on needs and risk assessment,
data analysis and technical guidance.
Key indicators
Percentage of adopted IYCF policies in emergencies that reflect the specifica-
tions of the Operational Guidance
No Code violations reported
Percentage of Code violations donations of breastmilk substitutes (BMS), liquid

milk products, bottles and teats dealt with in a timely manner
Guidance notes
Communication with the affected people, responders and media: Communicating
about available services and healthy infant and young child feeding practices will
186
require adapted messages for different groups providing assistance and for the
public. Consider the need to support caregivers who are grandparents, single
parents, child-headed households or siblings as well as caregivers with disabilities,
and people living with HIV when generating messages.
International Code of Marketing of Breastmilk Substitutes: The Code protects artificially
fed babies by ensuring safe use of breastmilk substitutes. It is based on impartial,
accurate information and applies in all contexts. It should be included in legislation
during the preparedness phase and enforced during the crisis response. In the absence
of national legislation, implement the Code provisions at a minimum.
The Code does not restrict the availability or prohibit the use of breastmilk substi-
tutes, feeding bottles or teats. It only restricts their marketing, procurement
and distribution. Common Code violations in crises derive from labelling issues
and untargeted distribution. During crises, monitor and report Code violations to
UNICEF, WHO and local authorities.
Use standard indicators where they exist and develop context-specific indica-
tors where they do not. Define IYCF-E benchmarks to determine progress and
achievement, considering intervention time frames. Encourage consistent IYCF-E
indicator use across implementing partners and in surveys. Repeat assessments
or parts of a baseline assessment as part of monitoring IYCF-E interventions.
Use annual surveys to determine the impact of these interventions.
Artificial feeding: All breastmilk substitutes must comply with Codex Alimentarius
and the Code. Access to adequate WASH services is essential to minimise the
risks of artificial feeding in emergencies. The distribution system for breastmilk
substitutes will depend on the context, including the scale of intervention. Do not
include infant formula and other breastmilk substitutes in general or blanket
food distributions. Do not distribute dried liquid milk products and liquid milk as a
single commodity. Indications for and management of artificial feeding should be
in accordance with the Operational Guidance and the Code, under the guidance of
the designated IYCF-E coordinating authority.
Infant and young child feeding standard 4.2:

Multi-sectoral support to infant and
young child feeding in emergencies
Mothers and caregivers of infants and young children have access to timely
and appropriate feeding support that minimises risks, is culturally sensitive
and optimises nutrition, health and survival outcomes.
Key actions
1
1. Prioritise pregnant and breastfeeding women for access to food, cash or
voucher transfers and other supportive interventions.
187
2.
2 Provide access to skilled breastfeeding counselling for pregnant and breast-
feeding mothers.
3.
3 Target mothers of all newborns with support for early initiation of exclusive
breastfeeding.
•• Provide simple guidance for exclusive breastfeeding in maternity services.
•• Protect, promote and support exclusive breastfeeding in infants aged
0–5 months, and continued breastfeeding in children aged six months to
two years.
•• Where mixed feeding is practised in infants aged 0–5 months, support
transitioning to exclusive breastfeeding.
4.
4 Provide appropriate breastmilk substitutes, feeding equipment and
associated support to mothers and caregivers whose infants require
artificial feeding.
•• Explore the safety and viability of relactation and wet nursing where infants
are not breastfed by their mother. Consider the cultural context and service
availability in such situations.
•• If breastmilk substitutes are the only acceptable options, include an essential
package of support with cooking and feeding equipment, WASH support and
access to healthcare services.
5.
5 Support timely, safe, adequate and appropriate complementary food support.
•• Assess household foods to assess whether they are suitable as complemen-
tary foods for children and provide context-specific advice and support on
complementary feeding.
•• Ensure access to feeding equipment and cooking supplies, with considera-
tions for children with feeding difficulties.
6.
6 Provide feeding support to particularly vulnerable infants and young children.
•• Support infant stimulation activities and early child development care

practices within nutrition programmes.
7.
7 Provide micronutrient supplements as necessary.
•• Provide daily supplements to pregnant and breastfeeding women,
including one daily requirement of multiple micronutrients to protect
maternal stores and breastmilk content, whether the women receive
fortified rations or not.
•• Continue iron and folic acid supplements when already provided.
Key indicators
Percentage of breastfeeding mothers who have access to skilled counselling
Percentage of caregivers who have access to Code-compliant supplies of

appropriate breastmilk substitutes (BMS) and associated support for infants
who require artificial feeding
188
Percentage of caregivers who have access to timely, appropriate, nutritionally

adequate and safe complementary foods for children aged 6 to 23 months
Guidance notes
IYCF-E assessment and monitoring: Assess the needs and priorities for IYCF-E
response and monitor the impact of IYCF-E interventions ⊕ see Food security and
nutrition assessments standard 1.2: Nutrition assessment.
Multi-sectoral collaboration: Sectoral entry points to identify and support
IYCF-E include:
•• ante-natal and post-natal care;

•• immunisation points;
•• growth monitoring;
•• early childhood development;
•• HIV treatment services (including prevention of mother-to-child transmission);
•• acute malnutrition treatment;
•• community health, mental health and psychosocial support;
•• WASH services;
•• places of employment; and
•• agricultural extension work.
Target groups: All assessment and programme data for children under five
years should be disaggregated by sex and by age 0–5 months, 6–11 months,
12–23 months, and 24–59 months. Disaggregation by disability is recommended
from 24 months.
Identify and establish services to provide for the nutritional and care needs of
children with disabilities, separated and unaccompanied infants and young children.
Refer separated and unaccompanied children to child protection partners. Identify
the proportion of pregnant and lactating women.
Consider populations with medium or high HIV prevalence, separated and unac-
companied children, low birth-weight infants, children with disabilities and with
feeding difficulties, children under two years not breastfeeding, and those acutely
malnourished. Be aware that children of mothers with depression tend to be at
higher risk of malnutrition.
Pregnant and breastfeeding women: If the needs of pregnant and breastfeeding
women are not met in food, or cash or voucher assistance programmes, target
pregnant and breastfeeding women with fortified food. Give micronutrient supple-
ments in accordance with WHO recommendations.
Organise psychosocial support for distressed mothers, including referral to mental
health services as necessary. Arrange appropriate support for mothers with disabilities.
Create safe places in camp and other collective settings for women to breastfeed,
such as baby friendly spaces with exclusive breastfeeding areas.
189
Breastfed infants: Planning and resource allocation should allow for skilled breast-
feeding support in difficult situations. This could include for acutely malnourished
infants aged 0–6 months, populations where mixed feeding is common, and infant
feeding in the context of HIV.
Non-breastfed infants: In all crises, protect infants and young children who
are not breastfed and support them to meet their nutritional needs. The
consequences of not breastfeeding vary by the age of the child. The youngest
children are most vulnerable to infectious diseases. They depend on access to
assured supplies of appropriate breastmilk substitutes, fuel, equipment and
WASH conditions.
Infant formula and other breastmilk substitutes: Infant formula is the appropriate
breastmilk substitute for infants aged 0–5 months. Give preference to ready-to-
use infant formula in liquid form, since it does not require preparation and carries
fewer safety risks than powdered infant formula.
Appropriate use, careful storage and hygiene of feeding utensils are essential for
ready-to-use infant formula. Ready-to-use infant formula is bulky and therefore
expensive to transport and store. In children over six months, use alternative liquid
milks. Alternative milks include pasteurised full-cream milk from a cow, goat,
sheep, camel or buffalo; ultra-high temperature liquid milk; fermented liquid milk;
or yogurt.
Use of infant formula in children over six months will depend on pre-crisis practices,
resources available, sources of alternative liquid milks, adequacy of complemen-
tary foods and humanitarian organisation policy. Indications for using breastmilk
substitutes may be short or longer term. Follow-on, growing-up liquid milks and
toddler liquid milks marketed to children over six months are not necessary.
A qualified health or nutrition worker can determine the need for infant formula
through individual assessment, follow-up and support. Where individual assess-
ment is not possible, consult with the coordinating authority and technical human-
itarian organisations for advice on assessment and targeting criteria. Provide
infant formula until the child is breastfeeding or at least six months. When provid-
ing breastmilk substitutes to children who need it, do not inadvertently encourage
breastfeeding mothers to use it also.
Do not use feeding bottles; they are difficult to clean. Encourage and support cup
feeding.
Maintain surveillance of morbidity at individual and population levels, with a focus
on diarrhoea.
Complementary feeding is the process that starts when breastmilk alone is no
longer sufficient to meet the nutritional requirements of infants and other foods
and liquids are needed along with breast milk. Complementary foods and liquids,
whether industrially produced or locally prepared, should be provided to children
aged 6–23 months.
190
Pre-existing and existing nutrient gaps are key in determining complementary food
support options. Other considerations include the affordability and availability of a
nutritious diet, seasonality of food supply and access to locally available comple-
mentary foods of good quality. Complementary food response options include:
•• cash-based assistance to purchase locally available fortified and nutrient-

rich foods;
•• distributing nutrient-rich household foods or fortified foods;
•• provision of multiple-micronutrient fortified foods to children aged 6–23
months;
•• home fortification with micronutrient supplements such as micronutrient
powders or other supplements;
•• livelihood programmes; and
•• safety net programmes.
Consider training or messaging alongside cash-based assistance, to ensure

affected people understand the optimal use of cash for nutritional outcomes.
Micronutrient supplementation: Children aged 6–59 months not receiving fortified
foods may require multiple micronutrient supplements to meet nutrition require-
ments. Vitamin A supplements are recommended. In malaria-endemic areas,
provide iron in any form, including micronutrient powders, and always in conjunc-
tion with malaria diagnosis, prevention and treatment strategies. Examples of
malaria prevention strategies are provision of insecticide-treated bed nets and
vector-control programmes, prompt diagnosis of malaria illness, and treatment
with effective anti-malarial drug therapy. Do not provide iron to children who do
not have access to malaria-prevention strategies. Provide iron and folic acid, or
multiple micronutrient supplements, to pregnant and lactating women, in accord-
ance with the latest guidance.
HIV and infant feeding: Mothers living with HIV should be supported to breastfeed
for at least 12 months and up to 24 months or longer while receiving anti-retroviral
therapy. If anti-retroviral drugs are not available, choose the strategy that gives
infants the greatest chance of HIV-free survival. This means balancing risks of
HIV transmission versus non-HIV causes of child death. Support mothers and
caregivers accordingly. Prioritise accelerated access to anti-retroviral drugs ⊕ see
Essential healthcare – sexual and reproductive health standard 2.3.3: HIV.
Counsel breastfeeding HIV-uninfected mothers and wet nurses, and those
whose HIV status is unknown, to breastfeed exclusively for the first six months
of the baby’s life. After that, introduce complementary foods while continuing
breastfeeding until the child is 24 months or more. Infants already established on
replacement feeding require urgent identification and support.
Consult existing national and sub-national policies and assess whether they
are in line with the latest WHO recommendations. Determine whether they are
appropriate for the new crisis context, considering the change in risk exposure
191
to non-HIV infectious disease, the likely duration of the emergency, whether

replacement feeding is possible and the availability of anti-retroviral drugs.
Updated interim guidance may need to be issued and communicated to mothers
and caregivers.
Gender-based violence, child protection and nutrition: Gender-based violence,
gender inequality and nutrition are often inter-related. Domestic violence can pose
a threat to the health and well-being of women and their children. Nutrition staff
should provide supportive and confidential referral for caregivers or children
exposed to gender-based violence or child abuse. Other elements to integrate
include counselling, working to establish women- and child-friendly treatment
sites, and regular monitoring of default rates and failure to respond to treatment.
Consider including specialised gender-based violence and child protection case-
workers as part of nutrition staff ⊕ see Protection Principles 3 and 4.
Public health emergencies: In public health crises, take steps to prevent any inter-
ruptions in access to health and feeding support services, to ensure continued
household food security and livelihoods, and to minimise disease transmission
risks via breastfeeding, as well as to minimise maternal illness and death. Refer to
WHO guidance where needed for cholera, Ebola and Zika virus guidance.
192
Food security
5. Food security
Food security exists when all people have physical and economic access to suffi-
cient, safe and nutritious food that meets their dietary needs and food preferences
for an active and healthy life.
Food security is influenced by macro-economic, socio-political and environmental
factors. National and international policies, processes or institutions can impact
affected people’s access to nutritionally adequate food. The degradation of the
local environment and the increasingly variable and extreme weather caused by
climate change also affect food security.
In a humanitarian crisis, food security responses should aim to meet short-term
needs and reduce the need for the affected population to adopt potentially
damaging coping strategies. Over time, responses should protect and restore
livelihoods, stabilise or create employment opportunities and contribute to
restoring longer-term food security. They should not have a negative impact on
natural resources and the environment.
Household food insecurity is one of four underlying causes of undernutrition, along
with poor feeding and care practices, an unhealthy household environment and
inadequate healthcare.
The standards in this section consider the resources to meet the food needs of
both the general population and people at increased nutritional risk, such as children
under five years of age, people living with HIV or AIDS, older people, people with
chronic illnesses and people with disabilities.
Responses aimed at treating malnutrition will have a limited impact if the food
needs of the general population are not met. People who recover from malnutri-
tion but who cannot maintain an adequate food intake will deteriorate again.
The choice of the most effective and efficient crisis response options requires
a thorough analysis of sex-disaggregated needs, household preferences, cost
efficiency and effectiveness, protection risks and seasonal changes. It should also
identify the specific type and quantity of food required and the optimal way of
distributing it.
Food is the major expenditure for vulnerable households. Cash-based assistance
can enable people receiving assistance to better manage their overall resources,
although this depends on the transfer value provided. Collaborative analysis and
programme objectives will guide the targeting, transfer value and any potential
conditions placed on the transfer.
Food security responses should progressively aim to work through or support local
markets. Decisions on local, national or regional procurement should be based on
an understanding of markets, including market and financial service providers.
193
Market-based programming, such as grants to traders for restocking, can also support
markets ⊕ see Delivering assistance through markets and MERS Handbook.
Food security standard 5:

General food security
People receive food assistance that ensures their survival, upholds their
dignity, prevents the erosion of their assets and builds resilience.
Key actions
1.
1 Based on food security assessment data, design the response to meet
immediate needs, and consider measures to support, protect, promote and
restore food security.
•• Consider both in-kind and cash-based options for the food basket.
2.
2 Develop transition and exit strategies for all food security programmes as
early as possible.
•• Integrate programmes with responses from other sectors.
3.
3 Ensure that people receiving assistance have access to the necessary know
ledge, skills and services to cope and support their livelihoods.
4.
4 Protect, preserve and restore the natural environment from further
degradation.
•• Consider the impact of cooking fuel on the environment.
•• Consider livelihoods strategies that do not contribute to deforestation or soil
erosion.
5.
5 Monitor the level of acceptance of and access to humanitarian food security
interventions by different groups and individuals.
6.
6 Ensure that people receiving food assistance are consulted on the design of
the response and are treated with respect and dignity.
•• Establish a mechanism for providing feedback.
Key indicators
Percentage of targeted households with acceptable Food Consumption Score
•• >35 per cent; if oil and sugar are provided, >42 per cent
Percentage of targeted households with acceptable Dietary Diversity Score

•• >5 main food groups regularly consumed
Percentage of targeted households with acceptable Coping Strategy Index
194
Food security
Percentage of people receiving assistance that report complaints or negative

feedback related to their treatment with dignity
•• All complaints are regularly monitored and quickly responded to.
Guidance notes
Context: Monitor the wider food security situation to assess the continued relevance
of a response. Determine when to phase out activities and when to introduce
modifications or new projects, and identify any need for advocacy.
In urban settings, take steps to contextualise household food expenditure indi-
cators, particularly in dense low-income settlements. For example, the Food
Expenditure Share and its established thresholds may be less accurate in urban
contexts, because non-food expenses, such as rent and heating, are relatively
higher.
Exit and transition strategies: Start developing exit and transition strategies from
the outset of the programme. Before closing a programme or making a transition,
there should be evidence of improvement or that another actor can take respon-
sibility. In the case of food assistance, it may mean understanding the existing or
planned social protection or long-term safety-net systems.
Food assistance programmes can coordinate with social protection systems or
lay the foundation for such a future system. Humanitarian organisations can also
advocate for systems that address chronic food insecurity, informed by a chronic
food insecurity analysis where available ⊕ see MERS Handbook.
At-risk groups: Use community-based risk assessments and other participatory
monitoring to counter any patterns that endanger particular groups or individuals.
For example, distributing fuel and/or fuel-efficient stoves may reduce the risks
of physical and sexual assault for women and girls. Supplemental cash transfers,
especially to vulnerable households or individuals, such as women- and child-
headed households or households with people with disabilities, can reduce the risk
of sexual exploitation and child labour.
Community support structures: Design community support structures together with
users, so that they are appropriate and adequately maintained and are more likely
to remain after the programme ends. Consider the needs of vulnerable individuals
during the design. For example, separated or unaccompanied girls and boys may
miss out on the information and skills development that takes place within a family
⊕ see Core Humanitarian Standard Commitment 4.
Livelihoods support: ⊕ See Food security and nutrition – livelihoods standards 7.1 and
7.2, MERS Handbook and LEGS Handbook.
Environmental impact: People living in camps require cooking fuel, which may
accelerate local deforestation. Consider options such as fuel distribution, efficient
stoves and alternative energy. Take account of the potential environmental
195
benefits of making vouchers more specific to environmentally sustainable goods

and services. Look for opportunities to change previous food and cooking customs
that may have caused environmental degradation. Consider climate change
trends. Prioritise activities that provide relief in the short term and reduce crisis
risk in the medium and long term. For example, destocking may locally reduce
pressure on pasture during a drought ⊕ see Shelter and settlement standard 7:
Environmental sustainability.
Access and acceptability: People are more likely to participate in a programme
that is easy to access and with acceptable activities. Use participatory design
with all members of the affected population to ensure overall coverage without
discrimination. While some food security responses target the economically
active, responses should be accessible to all people. To overcome constraints for
at-risk groups, actively work with them to design activities and set up appropriate
support structures.
196
Food assistance
6. Food assistance
Food assistance is required when the quality and quantity of available food
or access to food is not sufficient to prevent excessive mortality, morbidity or
malnutrition. It includes humanitarian responses that improve food availability
and access, nutrition awareness and feeding practices. Such responses should
also protect and strengthen the livelihoods of affected people. Response options
include in-kind food, cash-based assistance, support for production and market
support. While meeting immediate needs is a priority in the initial stages of a crisis,
responses should preserve and protect assets, help to recover assets lost through
crises and increase resilience to future threats.
Food assistance may also be used to prevent people adopting negative coping
mechanisms such as the sale of productive assets, over-exploitation or destruc-
tion of natural resources or the accumulation of debt.
A wide range of tools can be used in food assistance programmes, including:
•• general food distributions (provision of in-kind food, cash-based assistance

for purchase of food);
•• blanket supplementary feeding programmes;
•• targeted supplementary feeding programmes; and
•• providing relevant services and inputs, including transferring skills or
knowledge.
General food distributions provide support to those who need the food most.
Discontinue these distributions when the people receiving assistance can produce
or access their food through other means. Transitional arrangements may be
needed, including conditional cash-based assistance or livelihood support.
People with specific nutrient needs may require supplementary food in addition to
any general ration. This includes children aged 6–59 months, older people, persons
with disabilities, people living with HIV, and pregnant or breastfeeding women. In
many situations, supplementary feeding saves lives. On-site feeding is under-
taken only when people do not have the means to cook for themselves. This can
be necessary immediately after a crisis, during population movements or where
insecurity would put recipients of take-home rations at risk. It can also be used
for emergency school feeding, although take-home rations may be distributed
through schools. Consider that children not attending school will not access these
distributions; plan outreach mechanisms for these children.
Food assistance requires good supply chain management and logistics capabilities
to manage commodities effectively.
Management of any cash delivery system needs to be robust and accountable,
with systematic monitoring ⊕ see Delivering assistance through markets.
197
Food assistance standard 6.1:

General nutrition requirements
The basic nutritional needs of the affected people, including the most
vulnerable, are met.
Key actions
1.
1 Measure the levels of access to adequate quantity and the quality of food.
•• Assess the level of access on a frequent basis to see whether it is stable or
likely to decline.
•• Assess affected people’s access to markets.
2.
2 Design food and cash-based assistance to meet the standard initial planning
requirements for energy, protein, fat and micronutrients.
•• Plan rations to make up the difference between the nutritional requirements
and what people can provide for themselves.
3.
3 Protect, promote and support affected people’s access to nutritious foods
and nutritional support.
•• Ensure that children aged 6-24 months have access to complementary
foods and that pregnant and breastfeeding women have access to additional
nutritional support.
•• Ensure households with chronically ill members, people living with HIV and
tuberculosis, older people and people with disabilities have appropriate
nutritious food and adequate nutritional support.
Key indicators
Prevalence of malnutrition among children <5 years disaggregated by sex, and
disaggregated by disability from 24 months
•• Use WHO classification system (MAD, MDD-W).
•• For disaggregation by disability, use the UNICEF/Washington Group module
on Child Functioning.
Percentage of targeted households with acceptable Food Consumption Score

•• >35 per cent; if oil and sugar are provided, >42 per cent
Percentage of targeted households with acceptable Dietary Diversity Score

•• >5 main food groups regularly consumed
Percentage of targeted households that receive the minimum food energy

requirements (2,100kCal per person per day) and recommended daily micronu-
trient intake
198
Food assistance
Guidance notes
Monitoring access to food: Consider variables including levels of food security, access
to markets, livelihoods, health and nutrition. This will help determine whether the
situation is stable or declining, and whether food interventions are necessary. Use
proxy indicators such as the Food Consumption Score or dietary diversity tools.
Forms of assistance: Use appropriate forms of assistance (cash, vouchers or
in-kind) or a combination to ensure food security. Where cash-based assistance
is used, consider complementary food distributions or supplementary food distri-
butions to meet the needs of specific groups. Consider the adequacy of markets
to serve particular nutritional needs and use specific methodologies including ‘the
minimum cost of a healthy diet’ assessment tool.
Design of food rations and nutritional quality: A number of ration planning tools are
available, for example NutVal. To plan general rations ⊕ see Appendix 6: Nutritional
requirements. If a ration is designed to provide all the energy content of the diet,
then it must contain adequate amounts of all nutrients. If a ration provides only part
of the energy requirement of the diet, then design it using one of two approaches:
•• If the nutrient content of the other foods available to the population is

unknown, design the ration to provide a balanced nutrient content that is
proportional to the energy content of the ration.
•• If the nutrient content of the other foods available to the population is
known, design the ration to complement these foods by filling nutrient gaps.
The following estimates for a population’s minimum nutritional requirements

should be used for planning general rations and adjusted to context.
•• 2,100 kCal per person per day with 10–12 per cent of total energy provided
by protein and 17 per cent provided by fat ⊕ see Appendix 4: Nutritional
requirements for further details.
Ensuring adequate nutrient content of food rations may be challenging where there
are limited food types available. Consider access to iodised salt, niacin, thiamine and
riboflavin. Options for improving the nutritional quality of the ration include fortifying
staple commodities, including fortified blended foods, and encouraging the purchase of
locally produced fresh foods using vouchers. Consider using supplementation
products such as lipid-based, nutrient-dense, ready-to-use foods, or multiple
micronutrient tablets or powders. Provide IYCF-E messages to ensure that optimal
breastfeeding and complementary feeding practices are promoted ⊕ see Infant
and young child feeding standards 4.1 and 4.2.
When planning rations, consult with the community to take account of local and
cultural preferences. Choose foods that do not require long cooking if fuel is sparse.
Whenever there are changes in rations, share information with entire communi-
ties as early as possible to minimise resentment and limit the risk of household
199
violence against women, who may be blamed for reduced rations. Clearly commu-
nicate the exit plan from the onset to manage expectations, reduce anxiety and
enable households to make relevant decisions.
Link with health programmes: Food assistance can prevent the deterioration of
the nutrition status of the affected population, especially when combined with
public health measures to prevent diseases such as measles, malaria and parasitic
infection ⊕ see Health systems standard 1.1: Health service delivery and Essential
healthcare – communicable diseases standard 2.1: Prevention.
Monitoring food use: Key indicators for food assistance measure access to food
but do not quantify food use. Direct measurement of nutrient intake is not realistic.
Indirect measurement is a good alternative, using information from various
sources including food availability and use at the household level, and assessing
food prices, food availability and cooking fuel in local markets. Other options
include examining food assistance distribution plans and records, assessing any
contribution of wild foods and conducting food security assessments.
At-risk groups: When setting eligibility criteria for food assistance, consult with
different groups to identify any particular needs that might otherwise be over-
looked. Include adequate and acceptable food such as fortified blended food for
young children (aged 6–59 months) in the general ration. Specific population groups
that may need attention include older people, people living with HIV, persons with
disabilities, and caregivers.
Older people: Chronic disease and disability, isolation, large family size, cold weather
and poverty can reduce access to food and increase nutrient requirements. Older
people should be able to access food sources and food transfers easily. Foods
should be easy to prepare and consume and should meet the additional protein
and micronutrient requirements of older people.
People living with HIV: There is a high risk of malnutrition for people living with
HIV. This is due to factors such as reduced food intake, poor absorption of nutri-
ents, changes in metabolism, and chronic infections and illness. The energy
requirements of people living with HIV vary with the stage of the infection.
Milling and fortifying food, or providing fortified, blended or special food supple-
ments are possible strategies for improving access to an adequate diet. In some
situations it may be appropriate to increase the overall size of any food ration.
Refer malnourished people living with HIV to targeted feeding programmes,
when available.
Persons with disabilities, including people with psychosocial disabilities, may be at
particular risk of separation from immediate family members and usual caregivers
in a crisis. They also may face discrimination. Reduce these risks by ensuring
physical access to food, access to energy-dense and nutrient-rich foods, and
mechanisms for feeding support. This may include providing manual blenders,
spoons and straws, or developing systems for home visiting or outreach. In addition,
200
Food assistance
consider that children with disabilities are less likely to be enrolled in schools,
missing school-based food programmes.
Caregivers: It is important to support people caring for vulnerable individuals.
Caregivers and those they are caring for may face specific nutritional barriers.
For example, they may have less time to access food because they are ill or caring
for the ill. They may have a greater need to maintain hygienic practices. They may
have fewer assets to exchange for food, due to the costs of treatment or funerals.
They may face social stigma and reduced access to community support mechanisms.
Use existing social networks to train selected members of the population to
support caregivers.

Food quality, appropriateness and acceptability
The food items provided are of appropriate quality, are acceptable and can be
used efficiently and effectively.
Key actions
1.
1 Select foods that conform to the national standards of the host government
and other internationally accepted quality standards.
•• Perform random sample testing on food stocks.
•• Understand and respect national regulations concerning the receipt and use
of genetically modified foods when planning to use imported food.
2.
2 Choose appropriate food packaging.
•• Provide labels with the date of production, country of origin, expiration or
“best before” date, nutritional analysis and cooking instructions in access
ible formats and in the local language, especially for less familiar or less
commonly used foods.
3.
3 Assess access to water, fuel, stoves and food storage facilities.
•• Provide ready-to-eat foods when crises prevent access to cooking facilities.
4.
4 Provide access to adequate milling and processing facilities when whole-
grain cereal is provided.
•• Meet milling costs of recipients using cash or vouchers, or the less-preferred
approach of providing additional grain or milling equipment.
5.
5 Transport and store food in appropriate conditions.
•• Follow standards in storage management, with systematic checks on

food quality.
•• Measure quantities in consistent units; and avoid changing the units and the
measuring procedures during the project.
201
Key indicators
Percentage of affected population that report that food provided is of appropri-
ate quality and meets local preferences
Percentage of affected population that report the mechanism to receive food

was appropriate
Percentage of households that report that received food items were easy to
prepare and store
Percentage of people receiving assistance that report complaints or negative

feedback related to food quality
•• All complaints are regularly monitored and quickly responded to.
Percentage of food losses reported by the programme

•• Target <0.2 per cent of total tonnage.
Guidance notes
Food quality: Foods must conform to the food standards of the host country’s
government. Food must also conform to the Codex Alimentarius standards
about quality, packaging, labelling and fitness for purpose. When food is not
of the quality required for its intended use, it is unfit for the purpose. This is
true even if it is fit for human consumption. An example is when the quality of
flour may not enable baking at household level even if it is safe to consume.
Phytosanitary certificates or other inspection certificates must accompany
locally purchased and imported foods. Fumigation should use appropriate
products and follow strict procedures. Ensure that independent quality surveyors
inspect large-quantity consignments and use independent quality surveyors
when there are doubts or disputes about quality.
Ensure that host governments remain involved as much as possible. Obtain infor-
mation on the age and quality of food consignments from supplier certificates,
quality control inspection reports, package labels and warehouse reports. Make a
database for certificates of analysis (CoA) issued by a relevant authority to certify
the quality and purity of a product.
Assess availability of food commodities on local, national or international markets.
If food assistance is sourced locally, it should be sustainable and not further strain
local natural resources or distort markets. Factor potential food supply constraints
into programme planning.
Food packaging: Food losses can be reported at warehouses and final distri-
bution points. Food losses can be due to poor packaging in the distribution
cycle. Packaging should be sturdy and convenient for handling, storage and
distribution. It should be accessible for older people, children and persons with
202
Food assistance
disabilities. If possible, packaging should allow direct distribution without requiring

re-measuring or repacking.
Food packaging should not carry any messages that are politically or religiously
motivated or divisive in nature.
Packaging should not be a hazard, and humanitarian organisations have a respon-
sibility to prevent the environment becoming littered with packaging from items
distributed, or bought with cash or vouchers. Use minimal packaging (biodegradable
where possible) and locally appropriate materials, if possible by promoting a part-
nership with the local government and packaging material manufacturers. Provide
food receptacles that can be reused, recycled or re-appropriated. Dispose of waste
packaging in a way that prevents environmental degradation. Ready-to-use food
packaging, such as foil wrappers, may require specific controls for safe disposal.
Where litter occurs, organise regular community clean-up campaigns. These
campaigns should be part of community mobilisation and awareness-raising, rather
than as cash-for-work ⊕ see WASH solid waste management standards 5.1 to 5.3.
Food choice: While nutritional value is the primary consideration in providing food
assistance, the commodities should be familiar to the recipients. They should also
be consistent with religious and cultural traditions, including any food taboos for
pregnant or breastfeeding women. Consult women and girls on food choice, as in
many settings they have the primary responsibility for food preparation. Support
grandparents, men who are single heads of households, and youth in charge of
their siblings without support, as their access to food could be at risk.
In urban contexts, households are likely to access a more diverse range of foods
than in rural ones, but the quality of the diet may be limited, requiring different
nutritional support.
Infant feeding: Donated or subsidised infant formula, powdered milk, liquid milk
or liquid milk products should not be distributed as a separate commodity in a
general food distribution. These items should also not be distributed in a take-
home supplementary feeding programme ⊕ see Infant and young child feeding
standard 4.2.
Wholegrain cereal: Where household grinding is traditional or there is access to
local mills, distribute wholegrain cereals. Wholegrain cereal has a longer shelf life
than its alternatives and may have a higher value to programme participants.
Provide facilities for low-extraction commercial milling that removes germ, oil and
enzymes that cause rancidity. Low-extraction commercial milling greatly increases
shelf life, although it also reduces protein content. Milled whole maize has a shelf
life of only six to eight weeks, so milling should occur shortly before consumption.
Milled grain normally requires less cooking time. Milling requirements can some-
times expose women or adolescent girls to increased risk of exploitation. Work
with women and girls to identify risks and solutions such as providing support for
women-run mills.
203
Food storage and preparation: Household storage capacity should inform the choice
of foods offered. Ensure that people receiving assistance understand how to avoid
public health risks associated with food preparation. Provide fuel-efficient stoves
or alternative fuels to minimise environmental degradation.
Storage areas should be dry and hygienic, adequately protected from weather
and free of chemical or other contamination. Secure storage areas against pests
such as insects and rodents. Where appropriate, use Ministry of Health officers to
certify the quality of food supplied by vendors and traders.

Targeting, distribution and delivery
Food assistance targeting and distribution is responsive, timely, transparent
and safe.
Key actions
1.
1 Identify and target food assistance recipients based on need and consulta-
tions with appropriate stakeholders.
•• Provide clear, publicised details of targeting approaches that are accepted by
both recipient and non-recipient populations, to avoid creating tensions and
doing harm.
•• Initiate formal registration of households to receive food as soon as it is
feasible, and update as necessary.
2.
2 Design food distribution methods or direct cash/voucher delivery
mechanisms that are efficient, equitable, secure, safe, accessible
and effective.
•• Consult women and men, including adolescents and youth, and promote
participation by potentially vulnerable or marginalised groups.
3.
3 Locate distribution and delivery points where they are accessible, safe and
most convenient for the recipients.
•• Minimise risks to people reaching distributions, regularly monitoring
checkpoints or changes in the security situation.
4.
4 Provide recipients with advance details of the distribution plan and schedule,
the quality and quantity of the food ration or the cash or voucher value, and
what it is intended to cover.
•• Schedule distributions in a way that respects people’s travelling and working
time and that prioritises at-risk groups as appropriate.
•• Define and establish feedback mechanisms with the community before
distribution.
204
Food assistance
Key indicators
Percentage of inclusion and exclusion targeting errors minimised

•• Target <10 per cent
Distance from dwellings to final distribution points or markets (in case of
vouchers or cash)
•• Target <5 kilometres
Percentage of assisted people (disaggregated by sex, age and disability)

who report experiencing safety problems travelling (to and from) and at
programme sites
Number of cases reported of sexual exploitation or abuse of power related to

distribution or delivery practices
Percentage of cases of sexual exploitation or abuse of power related to distri-

bution or delivery practices that are followed up
•• 100 per cent
Percentage of targeted households that correctly cite their food assistance

entitlement
•• Target: >50 per cent of targeted households
Guidance notes
Targeting: Ensure that targeting tools and methods are adapted to context. Targeting
should span the intervention, not just the initial phase. Finding the right balance
between exclusion errors, which can be life-threatening, and inclusion errors, which
are potentially disruptive or wasteful, is complex. In rapid onset crises, inclusion errors
are more acceptable than exclusion errors. General food distributions may be appro-
priate in crises where households have suffered similar losses or where a detailed
targeting assessment is not possible due to lack of access.
Children aged 6–59 months, pregnant and lactating women, people living with
HIV and other vulnerable groups may be targeted for supplementary foods, or
they may be linked to nutrition treatment and prevention strategies. For people
living with HIV, this will increase their daily caloric intake and support adherence to
anti-retroviral therapy.
Any targeted programme should carefully avoid creating stigma or discrimination.
People living with HIV can be included as part of distributions for “people with
chronic diseases”, for instance, and provided through the health centres where
they receive care and treatment. Lists of people living with HIV should never
be publicised or shared, and in most contexts community leaders should not be
involved as targeting agents for people living with HIV.
205
Targeting agents/committees: Develop direct contact with affected people and

groups in the community, while avoiding community gatekeepers as much as
possible. Establish targeting committees that include representatives of the
following populations:
•• women and girls, men and boys, older people and persons with disabilities;
•• locally elected committees, women’s groups and humanitarian organisations;
•• local and international NGOs;
•• youth organisations; and
•• local governmental institutions.
The registration processes: Registration can be challenging in camps, especially where
displaced people do not have identification documents. Lists from local authorities
and community-generated household lists may be useful if an independent
assessment proves them accurate and impartial. Encourage the involvement
of affected women in designing the registration processes. Include at-risk individuals
on distribution lists, especially people with reduced mobility.
If registration is not possible in the initial stages of a crisis, complete it as soon as the
situation has stabilised. Establish a feedback mechanism for the registration process
that is accessible to all affected people, including women, girls, older people and
persons with disabilities. Women have the right to be registered in their own names.
Where possible, consult both men and women, separately if necessary, about who
should physically collect assistance or receive cash-based assistance on behalf of the
household. This consultation should be informed by a risk assessment.
Make special provision for single male- or female-headed households, as well as
child- and youth-headed households and separated or unaccompanied children,
so that they can safely collect assistance on behalf of their households. Establish
childcare adjacent to distribution points to enable single-parent households and
women with young children to collect assistance without leaving their children
unattended. In contexts where there are polygamous households, treat each wife
and her children as a separate household.
Distribution of “dry” rations: General food distributions normally only provide dry
rations, which people then cook in their homes. Recipients might include an individual
or a household ration-card holder, a representative of a group of households, traditional
and women leaders, or leaders of a community-based targeted distribution.
The frequency of distribution should consider the weight of the food ration
and the recipients’ means to carry it home safely. Specific support may be needed
to ensure that older people, pregnant and breastfeeding women, separated and
unaccompanied children, and persons with disabilities can collect and retain their
entitlements. Consider having other community members assist them, or provide
them with more frequent, smaller rations.
Distribution of “wet” rations: In exceptional circumstances, such as at the beginning
of a rapid-onset crisis, cooked meals or ready-to-eat food may be used for general
food distributions. These rations may be appropriate when people are on the move,
206
Food assistance
or when carrying food home would put people receiving assistance at risk of theft,
violence, abuse or exploitation. Use school meals and food incentives for education
personnel as a distribution mechanism in an emergency.
Distribution points: When locating distribution points, consider the terrain and try
to provide reasonable access to other sources of support such as clean and safe
water, toilets, health services, shade and shelter, and safe spaces for children and
women. The presence of armed checkpoints and military activity must be consid-
ered to minimise any risk to civilians and establish safe access to aid. Roads to
and from distribution points should be clearly marked, accessible and frequently
used by other members of the community. Consider the practicalities and costs of
transporting commodities ⊕ see Protection Principle 2.
Develop alternative means of distribution to reach those who are located further
from the distribution point or who have functional difficulties. Access to distribu-
tion is a common source of anxiety for marginalised and excluded populations in a
crisis. Provide direct distributions to populations in institutional settings.
Scheduling distributions: Schedule distributions at times that allow travel to distri-
bution points and back home during daylight hours. Avoid creating a requirement for
an overnight stay, which creates additional risks. Schedule distributions to minimise
disruption to everyday activities. Consider establishing fast-track or prioritisation
lines for at-risk groups, and a desk staffed with a social worker who can register
any unaccompanied and separated children. Provide advance information on the
schedule and distribution through a broad range of communications.
Safety during food, voucher and cash distributions: Take steps to minimise risks to
those participating in the distribution. This includes proper crowd control, supervision
of distributions by trained staff, and members of the affected population guarding
distribution points themselves. If necessary, involve the local police. Inform police offi-
cials and officers of the objectives of the food transfers. Carefully plan the site layout
at distribution points so that it is safe and accessible for older people, persons with
disabilities and people with functional difficulties. Inform all food distribution teams
about appropriate expected conduct, including penalties for sexual exploitation and
abuse. Include female guardians to oversee off-loading, registration, distribution and
post-distribution monitoring of food ⊕ see Core Humanitarian Standard Commitment 7.
Providing information: Display ration information prominently at distribution
points, in languages and formats accessible to people who cannot read or who
have communication difficulties. Inform people through printed, audio, SMS and
voice messages about:
•• the ration plan, specifying the quantity and type of food rations, or the cash/
voucher value and what it is intended to cover;
•• reasons for any changes from earlier plans (timing, quantity, items, other);
•• the distribution plan;
•• the nutritional quality of the food and, if needed, any special attention
required by recipients to protect its nutritional value;
207
•• the requirements for the safe handling and use of the foods;
•• specific information for optimum use of food for children; and
•• options for obtaining more information or providing feedback.
For cash-based assistance, transfer value should be included in ration informa-

tion. Information could be provided at the distribution point, displayed at the
cash out point or where vouchers can be redeemed, or in a leaflet in the local
language.
Changes to the food provided: Changes in rations or the transfer value for cash-
based assistance may happen due to a lack of available food, lack of funding or
other reasons. When this occurs, convey these changes to the recipients through
distribution committees, community leaders and representative organisations.
Develop a joint course of action before distributions. The distribution committee
should inform people of changes, the reasons behind the changes and the date and
plan for resuming normal rations. Options include:
•• reducing the rations to all recipients;

•• giving a full ration to vulnerable individuals and a reduced ration to the
general population; or
•• postponing the distribution (as a last resort).
Monitoring of distribution and delivery: Monitor food regularly by randomly

weighing rations collected by households to measure the accuracy and equity of
distribution. Interview recipients and ensure that the interview sample includes
an equal number of women and men, including adolescents and youth, persons
with disabilities and older people. Random visits by an interview team made up of
at least one male and one female can help determine the acceptability and useful-
ness of the ration. These visits can identify people who meet the selection criteria
but are not receiving food assistance. Such visits can also identify food received
from elsewhere, its source and its use. The visits can identify possible use of force
to take possessions, forcible recruitments, or sexual or other exploitation ⊕ see

Food use
Storage, preparation and consumption of food is safe and appropriate at
both household and community levels.
Key actions
1.
1 Protect people receiving assistance from inappropriate food handling or
preparation.
•• Inform people of the importance of food hygiene and promote good hygiene
practices in food handling.
208
Food assistance
•• Where cooked rations are provided, train staff in safe storage, handling and
preparation of food, and the potential health hazards of improper practices.
2.
2 Consult with and advise people receiving assistance on storage, preparation,
cooking and consumption of food.
3.
3 Ensure that households have safe access to appropriate cooking utensils,
fuel, fuel-efficient stoves, clean water and hygiene materials.
4.
4 Ensure that individuals who cannot prepare food or feed themselves have
access to caregivers who can support them where possible and appropriate.
5.
5 Monitor how food resources are used within the household.
Key indicators
Number of cases reported of health hazards from food distributed
Percentage of households able to store and prepare food safely
Percentage of targeted households able to describe three or more hygiene

awareness messages
Percentage of targeted households that report having access to appropriate

cooking utensils, fuel, drinking water and hygiene materials
Guidance notes
Food hygiene: Crises may disrupt people’s normal hygiene practices. Promote food
hygiene practices that are adapted to local conditions and disease patterns. Stress
the importance of avoiding water contamination, controlling pests and always
washing hands before handling food. Inform people receiving food about storing
food safely at the household level ⊕ see WASH hygiene promotion standards.
Food processing and storage: Access to food-processing facilities, such as cereal-
grinding mills, enables people to prepare food in the form of their choice and saves
time for other productive activities. Where perishable food items are offered,
consider appropriate facilities to store these, such as watertight containers, coolers
and freezers. Heat, cold and moisture influence the storage of perishable foods.
Individuals who may require assistance with storage, cooking and feeding
include young children, older people, people with disabilities and people living
with HIV. Outreach programmes or additional support may be necessary for
people who have difficulty providing food to their dependants, such as parents
with disabilities.
Intra-house food use monitoring: Humanitarian organisations should monitor and
assess intra-house use of food and its appropriateness and adequacy. At the
household level, food commodities can either be consumed as intended or be
traded or bartered. The goal of the barter could be to access other more-preferred
209
food items, non-food items or payment for services such as school fees or medical
bills. Intra-household allocation assessment should also monitor food use by sex,
age and disability.
The use of cash and vouchers: It is important to manage the risk of panic buying
when households receive cash or vouchers. Prepare traders and people receiving
assistance before distribution, at distribution and after distribution. For example,
consider whether food will be available throughout the month or whether it would
be better to stagger distributions over the course of a month. Vouchers can be
issued in small denominations redeemable on a weekly basis, where appropriate. The
same principle should apply to cash that is redeemable through automatic teller
machines or other forms of digital or manual payment.
210
Livelihoods
7. Livelihoods
People’s ability to protect their livelihoods is directly related to their vulnerability
to crises. Understanding vulnerabilities before, during and after a crisis makes it
easier to provide appropriate assistance, and to identify how communities can
rehabilitate and improve their livelihoods.
Crises can disrupt many of the factors that people rely on to maintain their liveli-
hoods. People affected by crises may lose their jobs or have to abandon their land
or water sources. Assets may also be destroyed, contaminated or stolen during
conflict or natural disasters. Markets may stop functioning.
In the initial stages of a crisis, meeting basic survival needs is the priority. However,
over time, rehabilitation of the systems, skills and capacities that support liveli-
hoods will also help people recover with dignity. Promoting livelihoods among
refugees often presents unique challenges, such as encampment or restrictive
legal and policy frameworks in countries of asylum.
Those who produce food need access to land, water, livestock, support services and
markets that can support production. They should have the means to continue produc-
tion without compromising other resources, people or systems ⊕ see LEGS Handbook.
In urban areas, the impact of a crisis on livelihoods is likely to be different from the
impact in rural areas. Household composition, skills, disabilities and education will
determine the degree to which people may participate in different economic activ-
ities. Generally, poorer urban people have a less diverse range of livelihoods coping
strategies than their counterparts in rural areas. For example, in some countries,
they cannot access land to grow food.
Bringing together those who have lost their livelihoods and those who influence
how new opportunities might be created will help to set the priorities of a liveli-
hoods response. This should reflect an analysis of labour, services and associated
product markets. All livelihoods interventions should consider how to use and/or
support local markets ⊕ see MERS Handbook.
Livelihoods standard 7.1:

Primary production
Primary production mechanisms receive protection and support.
Key actions
1.
1 Provide access to production inputs and/or assets for farmers.
•• Prefer cash or vouchers where markets are functioning and can be supported
to recover, to give farmers flexibility to select preferred inputs, seeds, fish
stock or livestock species.
211
•• Introduce new technologies after a crisis only if they have been tested in or
adapted to similar contexts.
2.
2 Deliver inputs that are locally acceptable, conform to appropriate quality
norms and are on time for best seasonal use.
•• Favour locally appropriate livestock inputs and local crop varieties that are
already in use and in demand for the upcoming season.
3.
3 Ensure inputs and services do not increase vulnerability for recipients or
create conflict within the community.
•• Assess potential competition for scarce natural resources (such as land or
water) as well as potential damage to existing social networks.
4.
4 Involve affected men and women equitably in planning, decision-making,
implementing and monitoring of primary production responses.
5.
5 Train producers engaged in crop, fishery, aquaculture, forestry and livestock
sectors in sustainable production and management practices.
6.
6 Assess the market and stimulate demand for locally produced crops,
vegetables and other agricultural products.
Key indicators
Percentage change in the targeted population’s production (food or income
source) compared with a normal year
Percentage of households reporting that they have access to adequate storage

facilities for their produce
Percentage of targeted households with improved physical access to function-

ing markets due to programme interventions
Guidance notes
Production strategies: Production strategies must have a reasonable chance of
developing and succeeding in context. This can depend on many factors, including
access to:
•• sufficient natural resources, labour, farm inputs and financial capital;

•• good quality seed varieties that are adapted to local conditions; and
•• productive animals, which represent a crucial food security asset ⊕ see LEGS
Handbook.
In addition, the strategy must consider existing livelihood skills, community prefer-
ences, the physical environment and potential for scalability.
Promote diverse livelihood activities within a local area, while preventing overuse
of natural resources. Environmental damage not only increases the risk of a crisis,
212
Livelihoods
but contributes to tensions between communities. Livelihoods interventions

should promote adaptation to climate change where possible, such as selecting
adapted seed varieties.
Prevent child labour associated with livelihoods initiatives. Be aware of the indirect
impact of livelihoods programmes on children, such as missing school because
they are required to support the household while a parent is working.
Energy: Consider energy needs for mechanised labour, food processing, communi-
cation, cold chains for food preservation and efficient burning devices.
Improvements: Consider introducing improved crop varieties, livestock or fish-stock
species, new tools, fertilisers or innovative management practices. Strengthen
food production based on the maintenance of pre-crisis patterns and/or links with
national development plans.
New technologies: Producers and local consumers must understand and accept
the implications of new technologies for local production systems, cultural
practices and the natural environment before adopting them. When introducing
new technologies, provide appropriate community consultations, information
and training. Ensure access for groups at risk of discrimination (including
women, older people, minorities and people with disabilities). If possible,
coordinate with livelihood experts and government ministries. Ensure ongoing
technological support, future accessibility to the technology, and assess its
commercial viability.
Cash-based assistance or credit: This can be provided to use at seed and livestock
fairs. Understand the potential consequences of a chosen approach on people’s
nutrition, considering whether it allows people to produce nutrient-rich food
themselves or whether it provides cash to purchase food. Assess the feasibility of
cash-based assistance for purchasing production inputs, considering availability
of goods, access to markets and the existence of a safe, affordable and gender-sen-
sitive cash transfer mechanism ⊕ see MERS Handbook and LEGS Handbook.
Seasonality and price fluctuations: Provide agricultural inputs and veterinary
services to coincide with the relevant agricultural and animal husbandry
seasons. For example, provide seeds and tools before the planting season.
Destocking of livestock during drought should take place before excess livestock
mortality occurs. Restocking should start when the likelihood of recovery is
high, for example following the next rainy season. When necessary, or provide
food assistance to protect seeds and inputs. Ensure that inputs are sensitive
to the different capacities, needs and risks of various groups, including women
and persons with disabilities. Extreme seasonal price fluctuations adversely
affect poor agricultural producers who sell their produce just after harvest,
when prices are at their lowest. These fluctuations also have a negative impact
on livestock owners who have to sell during drought. Conversely, consumers
who have limited disposable income cannot afford to invest in food stocks.
They depend on small but frequent purchases. As a result, they buy food
213
even when prices are high, such as during a drought. For livestock guidance
⊕ see LEGS Handbook.
Seeds: Farmers and local agricultural experts should approve specific varieties.
Seeds should suit the local agro-ecology and farmers’ own management conditions.
They should also be disease-resistant and withstand potentially harsh weather
conditions due to climate change. Test the quality of seeds originating from
outside the region and check that they are appropriate for local conditions. Give
farmers access to a range of crops and varieties in any seed-related intervention.
This allows them to work out what is best for their particular farming system.
For example, farmers growing maize may prefer hybrid seeds to local varieties.
Comply with government policies regarding hybrid seeds. Do not distribute genet-
ically modified seeds without the approval of local authorities. Inform farmers if
they are provided with genetically modified seeds. When farmers use vouchers
or seed fairs, encourage them to buy seeds from local formal suppliers. Farmers
may prefer traditional varieties which are adapted to the local context. These will
definitely be available at a lower price, meaning they get more seeds for the same
voucher value.
Community tensions and security risks: Tensions between the displaced and
local population or within the affected community can arise when production
requires a change in access to the available natural resources. Competition
over water or land can lead to restrictions in their use. Primary food production
may not be viable if there is a shortage of vital natural resources over the long
term. It is also not feasible if there is a lack of access for certain populations,
such as landless people. Providing free inputs can also disrupt traditional
social support, compromise redistribution mechanisms or affect private sector
operators. This can create tensions and reduce future access to inputs ⊕ see
Protection Principle 1.
Supply chain: Use existing local, verifiable supply chains to obtain inputs and
services for food production, such as veterinary services and seeds. To support
the local private sector, use mechanisms such as cash or vouchers that link
primary producers directly to suppliers. When designing local purchasing systems,
consider the availability of appropriate inputs and suppliers’ capacity to increase
supply. Assess the risk of inflation and the sustainability of the quality of inputs.
Monitor and mitigate the negative effects of responses, including large localised
food purchases and distribution, on market prices. Consider the effects of local
food purchases and imports on local economies. When working with the private
sector, identify and address gender inequalities and share any profits equitably
⊕ see MERS Handbook.
Monitor whether producers actually use the provided inputs as intended. Review
the quality of the inputs in terms of their performance, their acceptability and
producer preferences. Evaluate how the project has affected food availability
at household level. For example, consider the quantity and quality of food that
214
Livelihoods
is being stocked, consumed, traded or given away. Where the project aims to
increase production of a specific food type (animal/fish products or protein-rich
legumes), investigate the households’ use of these products. Include an analysis of
the benefit to different members of the household, such as women, children, older
people and people with disabilities.
Post-harvest storage: A significant proportion of produce (estimated average of
30 per cent) is unusable after harvest, due to losses. Support affected people to
minimise losses by managing handling, storage, processing, packaging, trans-
portation, marketing and other post-harvest activities. Advise and enable them
to store their harvest to avoid moisture and aflatoxins produced by fungi. Enable
them to process their crops, especially cereals.
Livelihoods standard 7.2:

Income and employment
Women and men receive equal access to appropriate income-earning
opportunities where income generation and employment are feasible
livelihood strategies.
Key actions
1.
1 Base decisions regarding income-earning activities on a gender-sensitive
market assessment.
•• Reduce the risk of undernutrition and other public health risks by ensuring
that participation in income-earning opportunities does not undermine
childcare or other caring responsibilities.
•• Understand labour rates for community members and the government
minimum wage for unskilled and skilled work.
2.
2 Choose types of payment (in-kind, cash, voucher, food or a combination)
based on a participatory analysis.
•• Understand local capacities, safety and protection benefits, immediate
needs, equitable access, existing market systems and the affected people’s
preferences.
3.
3 Base the level of payment on the type of work, local rules, objectives
for livelihoods restoration and prevailing approved levels of payment in
the region.
•• Consider safety-net measures such as unconditional cash and food transfers
for households that cannot participate in work programmes.
4.
4 Adopt and maintain inclusive, safe and secure working environments.
•• Monitor the risk of sexual harassment, discrimination, exploitation and

abuse in the workplace and respond quickly to complaints.
215
5.
5 Promote partnerships with the private sector and other stakeholders to
create sustainable employment opportunities.
•• Provide capital resources equitably to facilitate livelihood recovery.
6.
6 Choose environmentally sensitive options for income generation whenever
possible.
Key indicators
Percentage of the target population who improve their net income during a
defined period
Percentage of households with access to credit
Percentage of the target population who diversify their income-generating

activities
Percentage of the target population employed (or self-employed) in sustainable

livelihoods activities for a defined period of time (6–12 months)
Percentage of the affected population with physical and economic

access to functioning markets and/or other livelihood support services
(formal or informal)
Guidance notes
Analysis: A gender-sensitive labour and market analysis is fundamental to justify
and define activities, promote recovery and resilience, and sustain outcomes.
Understanding the household roles and responsibilities is essential to address any
opportunity costs, such as caring for children or older people, or accessing other
services such as education or healthcare.
Use existing tools to understand markets and economic systems. Food security
responses should be based on market functions before and after the crisis, and
their potential for improving the living conditions for poor people. Discuss alter-
natives or adaptations for at-risk groups (such as youth, persons with disabilities,
pregnant women or older people) within the targeted group. Analyse their skills,
experience and capacities, and potential risks and mitigation strategies. Explore
whether household members normally migrate for seasonal work. Understand
how different groups of the affected population may have restricted access to
markets and livelihoods opportunities, and support them in getting access.
Safety-net measures: Some women and men may not be able to participate in
income-generating activities, such as an elderly couple. The crisis itself may make
it impossible for others to participate in employment due to changes in respon-
sibilities or health status. Short-term safety-net measures can support such
cases, with links to existing national social protection systems. Recommend new
safety nets where needed. Delivery of safety-net measures must support the
216
Livelihoods
fair distribution of resources, ensuring that women and girls have direct access to
resources where appropriate. At the same time, work with safety-net recipients to
find ways for them to transition to safe and sustainable income-generating activ-
ities. Whenever possible, cash-based responses should be linked to existing safe-
ty-net programmes as part of sustainability and the social protection strategy.
Payments: Conduct a market analysis before implementing any paid work programme.
Payment may be in cash or in food or a combination of these and should enable
food-insecure households to meet their needs. Communicate project objectives,
the humanitarian organisation’s expectations of workers, the conditions under which
people will be working and the payment amount and process.
Make payment an incentive for people to improve their own situation, rather
than compensation for any work in the community. Consider people’s purchasing
needs and the impact of giving cash or food to create household income to meet
basic needs such as school, healthcare and social obligations. Decide on the type
and level of payment case by case. Monitor to ensure that all women and men are
paid equally for agreed units of work and that there is no discrimination against
specific groups.
Consider the impact of resale values on local markets where payment is in-kind and
provided as an income transfer. New income-generating activities should enhance
rather than replace the existing range of income sources. Payment should not have
a negative impact on local labour markets, for example by causing wage inflation,
diverting labour from other activities or undermining essential public services.
Purchasing power: Provision of cash may have positive multiplier effects in local
economies, but can also cause local inflation for key goods. Food distribution can
also affect the purchasing power of people receiving assistance. The purchasing
power associated with a given food or combination of foods influences whether
the recipient’s household eats or sells that food. Some commodities (such as oil)
are easier to sell for a good price than others (such as blended food). Establish an
understanding of household food sales and purchases when assessing the wider
impact of food distribution programmes.
Safety at work: Use practical procedures for minimising public health risk or treating
injuries. For example, provide training, protective clothing and first-aid kits where
necessary. Minimise the risk of exposure to communicable diseases and HIV.
Establish safe access routes to work sites, providing workers with torches where
the route is not well lit. Use bells, whistles and radios to warn of threats. Encourage
travelling in groups and avoid travelling after dark. Ensure that all participants
are aware of emergency procedures and can access early warning systems. Women
and girls should be equally protected, and any discriminatory norms in the workplace
should be addressed.
Managing household and family duties: Speak regularly with affected people,
including women and men separately, to learn their preferences and prior-
ities regarding income generation, cash-for-work opportunities, and other
217
household and family needs. Discuss workloads and any increased tensions
in the home due to changes in traditional gender roles and women’s increased
control over assets.
Cash-for-work activity schedules should consider the physical condition and daily
routines of men and women and be culturally appropriate. For example, they
should consider prayer times and public holidays. Working hours should not place
unreasonable competing demands on people’s time. Programmes should not
divert household resources away from existing productive activities, nor should
they adversely affect access to other employment or education. Participation in
income generation should respect national laws on the minimum employment
age. This is usually not less than the age of completion of compulsory schooling.
Childcare facilities with appropriate financial allocation are recommended at the
work sites if caregivers with small children are participating in the programme.
Environmental management: Support people’s engagement in environmental
activities such as tree planting, camp clean-up and environmental rehabilitation
through food and cash-for-work programmes. Though temporary, these activities
will increase people’s engagement in their surrounding environment.
Consider the accessibility and safety of the working environment. Ensure that any
debris to be cleared does not contain hazardous materials. Cash-for-work programmes
should not involve any clearance at industrial or waste management sites.
Promote the production of environmentally sustainable construction materials as
an income-generating activity and provide associated vocational training. Train
people and encourage composting of biodegradable waste for use as fertiliser.
Private sector: The private sector can play an important role in facilitating livelihood
protection and recovery. Where possible, establish partnerships to create employment
opportunities. These partnerships can also help to establish and grow micro, small
and medium enterprises. Business and technology incubators can provide financial
capital and opportunities for knowledge transfer ⊕ see MERS Handbook.
218
Appendix 1 – Food security and livelihoods assessment checklist
Appendix 1
Food security and livelihoods assessment
checklist
Food security assessments often broadly categorise the affected people into live-
lihood groupings according to their sources of, and strategies for, obtaining income
or food. This may also include a breakdown of the population according to wealth
groups or strata. It is important to compare the current situation with the history of
food security before the crisis. Use “average normal years” as a baseline. Consider
the specific roles and vulnerabilities of women and men, and the implications of
these for household food security.
The following checklist questions cover the broad areas to consider in a food security
assessment.
Food security of livelihood groups

•• Are there groups in the population who share the same livelihood strategies?
How can these be categorised according to their main sources of food or
income?
Food security before the crisis (baseline)

•• How did the different livelihood groups acquire food or income before the
crisis? For an average year in the recent past, what were their sources of
food and income?
•• How did these different sources of food and income vary seasonally and
geographically in a normal year? Constructing a seasonal calendar may be
useful.
•• Were all groups getting enough food of the right quality to be well nourished?
•• Were all groups earning enough income by non-harmful ways to afford their
basic needs? Consider food, education, healthcare, soap and other household
items, clothing, and productive inputs such as seeds and tools. (The last two
questions will indicate whether there were chronic problems. Existing prob-
lems may be worsened by a crisis. The appropriate response is influenced by
whether the problem is chronic or acute.)
•• Looking back over the past five or ten years, how has food security varied
from year to year? Constructing a timeline or history of food security may
be useful.
•• What kind of assets, savings or other reserves do the different livelihood
groups own? Examples include food stocks, cash savings, livestock holdings,
investments, credit and unclaimed debt.
•• Over a period of a week or a month, what do household expenditures
include? What proportion is spent on each item?
219
•• Who is responsible for the management of cash in the household and on

what is cash spent?
•• How accessible is the nearest market for obtaining basic goods? Consider
factors such as distance, security, ease of mobility, availability and accessi-
bility of market information, and transport.
•• What is the availability and price of essential goods, including food?
•• Before the crisis, what were the average terms of trade between basic needs
(food, agricultural inputs, healthcare, etc) and income sources (cash crops,
livestock, wages, etc)
Food security during crises

•• How has the crisis affected the different sources of food and income for each
of the livelihood groups identified?
•• How has it affected the usual seasonal patterns of food security for the
different groups?
•• How has it affected access to financial service providers, markets, market
availability and prices of essential goods?
•• For different livelihood groups, what are the different crisis coping strategies
and what proportion of people are engaged in them? How has this changed
compared with the situation before the crisis?
•• Which group or population is most affected?
•• What are the short- and medium-term effects of coping strategies on
people’s financial and other assets?
•• For all livelihood groups, and all people at risk, what are the effects of coping
strategies on their health, general well-being and dignity? Are there risks
associated with coping strategies?
220
Appendix 2 – Seed security assessment checklist
Appendix 2
Seed security assessment checklist
Below are sample questions for seed security assessments. Assessment of seed
security should consider national legislation on hybrid and genetically modified
varieties.
Seed security before the crisis (baseline)

•• What are farmers’ most important crops? What do they use them for –
consumption, income or both? Are these crops grown each season? What
other crops might become important in times of stress?
•• How do farmers usually get seed or other planting material for these crops?
Consider all channels.
•• What are the sowing parameters for each major crop? What is the average
area planted? What are the seeding rates? What are the multiplication rates
(ratios of seed or grain harvested to seed planted)?
•• Are there important or preferred varieties of specific crops (local climate-
adapted varieties)?
•• Which production inputs are essential for particular crops or varieties?
•• Who in the household is responsible for decision-making, managing crops
and disposing of crop products at different stages of production and
post-production?
Seed security after a crisis

•• Is a farming-related intervention feasible from the point of view of persons
receiving assistance?
•• Which crops have been affected most by the crisis? Should the focus be on
these? Why or why not?
•• Are farmers confident the situation is now stable and secure enough that
they can successfully cultivate, harvest and sell or consume a crop?
•• Do they have sufficient access to fields and other means of production
(manure, implements, draught animals)?
•• Are they prepared to re-engage in agriculture?
Assessing seed supply and demand: home stocks

•• Are adequate amounts of home-produced seed available for sowing?
This includes both seed from a farmer’s own harvest and seed potentially
available through social networks (for example, neighbours).
•• Is this a crop that farmers still want to plant? Is it adapted to local condi-
tions? Is there still a demand for it?
•• Are the varieties available through a farmer’s own production still suitable
for planting next season? Does the quality of the seed meet the farmer’s
normal standards?
221
Assessing seed supply and demand: local markets

•• Are markets generally functioning despite the crisis (are market days being
held, are farmers able to move, sell and buy freely)?
•• Are current volumes of available seed or grain comparable to those under
normal conditions at the same time during previous seasons?
•• Are crops and varieties that farmers find suitable for growing found in the
markets?
•• Are current market prices of seed or grain comparable to the prices at the
same time in previous seasons? If there is a price differential, is the magni-
tude likely to be a problem for farmers?
Assessing seed supply and demand: formal sector

•• Are the crops and varieties on offer from the formal sector adapted to
particular stress zones? Is there evidence farmers will use them?
•• Can the available formal sector seed meet the demand triggered by the
crisis? If not, what proportion of farmers’ needs will they meet?
222
Appendix 3 – Nutrition assessment checklist
Appendix 3
Nutrition assessment checklist
Below are sample questions for assessments examining the underlying causes
of undernutrition, the level of nutrition risk and the possibilities for response.
The questions are based on the conceptual framework of the causes of under-
nutrition. ⊕ See Figure 7 Food security and nutrition: causes of undernutrition.
The information is likely to be available from a variety of sources. Gathering
it will require various assessment tools, including key informant interviews,
observation and review of secondary data.
Pre-emergency situation
What information already exists on the nature, scale and causes of undernutri-
tion among the affected people? ⊕ See Food security and nutrition assessments
standard 1.1.
The current risk of undernutrition

What is the risk of undernutrition related to reduced food access?
⊕ See Appendix 1: Food security and livelihoods assessment checklist.
What is the risk of undernutrition related to infant and young child feeding and
care practices?
•• Is there a change in work and social patterns (due to factors such as migra-
tion, displacement or armed conflict) affecting the roles and responsibilities
in the household?
•• Is there a change in the normal composition of households? Are there large
numbers of separated children?
•• Has the normal care environment been disrupted (for example, through
displacement), affecting access to secondary caregivers, access to foods or
access to water?
•• Are any infants not breastfed? Are there infants who are artificially fed?
•• Has there been any evidence or suspicion of a decline in infant feeding
practices in the crisis? In particular, has there been a decrease in breast-
feeding initiation or exclusive breastfeeding rates? Has there been an
increase in artificial feeding rates and/or any increase in the proportion of
infants not breastfed?
•• Are age-appropriate, nutritionally adequate, safe complementary foods, and
the means to prepare them, hygienically accessible?
•• Is there any evidence or suspicion of general distribution of breastmilk
substitutes such as infant formula, other milk products, bottles and teats,
either donated or purchased?
223
•• In pastoral communities, have the herds been away from young children for
long? Has access to milk changed from normal?
•• Has HIV affected caring practices at household level?
•• Has the general food ration been adapted to the needs of older people and
people with difficulties feeding? Evaluate its energy composition and micro-
nutrient content. Assess the acceptability of the food products (palatability,
chewability and digestibility).
What is the risk of undernutrition related to poor public health?

•• Are there any reports of disease outbreaks that may affect nutritional
status, such as measles or acute diarrhoeal disease? Is there a risk that
these outbreaks will occur? ⊕ See Essential healthcare – communicable
diseases standard 2.1.
•• What is the estimated measles vaccination coverage of the affected people?
⊕ See Essential healthcare – child health standard 2.2.1.
•• Is vitamin A routinely given with measles vaccination? What is the estimated
vitamin A supplementation coverage?
•• Are there any estimates of mortality rates (either crude or under-five)?
What are the estimates and what method has been used to make them?
⊕ See Essential concepts in health.
•• Is there, or will there be, a significant decline in ambient temperature that
is likely to affect the prevalence of acute respiratory infection or the energy
requirements of the affected people?
•• Is there a high prevalence of HIV?
•• Are people already vulnerable to undernutrition due to poverty or ill
health?
•• Is there overcrowding or a risk of or high prevalence of tuberculosis?
•• Are there reported cases of non-communicable diseases such as diabetes,
arthritis, cardiovascular diseases and anaemia?
•• Is there a high incidence of malaria?
•• Have people been in water or in wet clothes or exposed to other harsh
environmental conditions for long periods of time?
What formal and informal local structures are currently in place through which
potential interventions could be channelled?
•• What is the capacity of the Ministry of Health, religious organisations,
community support groups, breastfeeding support groups or NGOs with a
long- or short-term presence in the area?
•• What nutrition interventions or community-based support were already in
place and organised by local communities, individuals, NGOs, government
organisations, UN agencies or religious organisations? What are the nutri-
tion policies (past, ongoing and lapsed), the planned long-term nutrition
responses, and programmes that are being implemented or planned in
response to the current situation?
224
Appendix 4 – Measuring acute malnutrition
Appendix 4
Measuring acute malnutrition
In major nutritional emergencies, it may be necessary to include infants under six
months, pregnant and breastfeeding women, older children, adolescents, adults
and older people in nutrition assessments or nutritional programmes.
Infants under six months

While research is ongoing for this age group, there is a limited evidence base for
assessment and management. Most guidelines recommend the same anthro-
pometric case definitions of acute infant malnutrition as for older children aged
6–59 months (except for mid upper arm circumference (MUAC), which is not
presently recommended for infants under six months). Admission criteria focus on
current size rather than an assessment of growth.
The switch from National Center for Health Statistics (NCHS) growth references
to WHO 2006 growth standards results in more cases of infants under six months
being recorded as wasted. This can result in more infants presenting to feeding
programmes, or caregivers becoming concerned about the adequacy of exclusive
breastfeeding. It is important to assess and consider the following:
•• The infant’s longitudinal growth – is the growth rate good, despite body size
being small (some infants may be “catching up” following low birth weight)?
•• Infant feeding practices – is the infant exclusively breastfeeding?
•• Clinical status – does the infant have any medical complications or condi-
tions that are treatable or that make him or her high risk?
•• Maternal factors – for example, does the mother lack family support or is
she depressed? Inpatient admission to therapeutic feeding programmes
should be a priority for high-risk infants.
Children aged 6–59 months

The table below shows the commonly used cut-offs for acute malnutrition among
children aged 6–59 months. Calculate weight-for-height (WFH) indices using the
WHO 2006 child growth standards. The WFH Z score (according to WHO standards) is
the preferred indicator for reporting anthropometric survey results. MUAC is an inde-
pendent criterion for acute malnutrition and is one of the best predictors of mortality.
The prevalence of low MUAC is also used to predict caseloads for supplementary
feeding and therapeutic care programmes. The cut-offs commonly used are <11.5
centimetres for severe acute malnutrition and 11.5–12.5 centimetres for moder-
ate acute malnutrition. MUAC is also often used, with a higher cut-off, as part of a
two-stage screening process. It should not be used alone in anthropometric surveys,
although it can be used as the sole admission criterion for feeding programmes.
225
Global acute Moderate acute Severe acute

malnutrition malnutrition malnutrition
Children 6–59 WFH <−2 Z score WFH −3 to −2 Z score WFH <−3 Z score
months and/or and/or and/or
MUAC <12.5cm MUAC 11.5–12.5cm MUAC <11.5cm
and/or and/or
nutritional oedema nutritional
oedema
Older people MUAC 21cm MUAC 18.5–21.0cm MUAC 18.5cm
Pregnant and MUAC <23cm MUAC 18.5–22.9cm MUAC <18.5cm
lactating women (may be <210mm in
certain contexts)
Adults BMI <18.5 BMI 16–18.5 BMI <16
(including people
living with HIV or
tuberculosis)
Children aged 5–19 years

Use the WHO 2007 growth standards to determine nutrition status in children
aged 5–19 years. These growth reference data curves align closely with the
WHO child growth standards for children aged 6–59 months and the recom-
mended cut-offs for adults. Consider using MUAC in older children and adoles-
cents, particularly in the context of HIV. As this is a developing technical area, it is
important to refer to the latest guidance and technical updates.
Adults (20–59 years)

There is no agreed definition of acute malnutrition in adults, but evidence suggests
that the cut-off for severe acute malnutrition could be a body mass index (BMI)
lower than 16, and for mild and moderate acute malnutrition lower than 18.5.
Surveys of adult malnutrition should aim to gather data on weight, height and
sitting height and MUAC measurements. This data can be used to calculate BMI.
BMI should be adjusted for the Cormic index (the ratio of sitting height to standing
height) only to make comparisons between populations. Such adjustment can
substantially change the apparent prevalence of undernutrition in adults and may
have important consequences for programming. MUAC measurements should
always be taken. If immediate results are needed or resources are severely limited,
surveys may be based on MUAC measurements alone.
The lack of validated functional outcome data and benchmarks complicates the
interpretation of anthropometric results. Use detailed contextual information when
interpreting them. For guidance on assessment ⊕ see References and further reading.
When screening individuals for nutritional care admission and discharge, use a
combination of anthropometric indices, clinical signs (particularly weakness, recent
weight loss) and social factors (such as access to food, presence of caregivers, shel-
ter). Note that oedema in adults can be caused by factors other than malnutrition,
226
Appendix 4 – Measuring acute malnutrition
and clinicians should assess adult oedema to exclude other causes. Individual
humanitarian organisations should decide on the indicator to determine eligibility
for care, taking into account the known shortcomings of BMI, the lack of infor-
mation on MUAC and the programme implications of the indicators’ use. This is a
developing technical area, so refer to the latest guidance and technical updates.
MUAC may be used as a screening tool for pregnant women, for example as a
criterion for entry into a feeding programme. Given their additional nutritional
needs, pregnant women may be at greater risk than other groups in the popula-
tion. MUAC does not change significantly through pregnancy. A MUAC of less than
20.7 centimetres indicates a severe risk of foetal growth retardation, and less than
23 centimetres indicates a moderate risk. Suggested cut-off points for risk vary by
country, but range from 21 to 23 centimetres. Consider less than 21 centimetres
as an appropriate cut-off for selection of women at risk during emergencies.
Older people
There is currently no agreed definition of malnutrition in older people, yet this group
may be at risk of malnutrition in crises. WHO suggests that the BMI thresholds for
adults may be appropriate for people aged over 60 years. However, accuracy of
measurement is problematic because of spinal curvature (stooping) and compression
of the vertebrae. Arm span or demi-span can be used instead of height, but the
multiplication factor to calculate height varies according to the population. Visual
assessment is necessary. MUAC may be a useful tool for measuring malnutrition in
older people, but research on appropriate cut-offs is still in progress.

No guidelines currently exist for the measurement of individuals with physical
disabilities. This lack of guidelines often excludes them from anthropometric
surveys. Visual assessment is necessary. MUAC measurements may be misleading
in cases where upper arm muscle might build up to aid mobility. There are alternatives
to standard measures of height, including length, arm span or demi-span or lower
leg length. It is necessary to consult the latest research to determine the most
appropriate way of measuring persons with disabilities for whom standard weight,
height and MUAC measurement is not appropriate.
227
Appendix 5
Measures of the public health significance
of micronutrient deficiencies
Urgently treat clinical micronutrient deficiencies on an individual basis. Individual
cases of clinical micronutrient deficiencies are also usually indicative of an under-
lying problem of micronutrient deficiency at the population level. Measuring and
classifying micronutrient deficiencies at the population level is important for
planning and monitoring interventions.
Biochemical tests provide an objective measure of micronutrient status. However,
the collection of biological samples for testing often presents logistical, staff
training, cold chain and sometimes acceptability challenges. Also, biochemical
measurements are not always as sensitive and specific as required. As with acute
malnutrition, there may be variations according to the time of day or season of the
year when the sample is collected. Good quality control is essential and should
always be considered when selecting a laboratory for sample testing.
When assessing micronutrient status, consider the possibility of excessive intakes
as well as deficiency. This is of particular concern when multiple highly fortified
products or supplements are used to deliver micronutrients.
Micronutrient deficiencies have severe consequences for older people’s mental
and physical health, their immune system and their functional abilities.
The table below shows classifications of the public health significance of selected
micronutrient deficiencies using different indicators. For information about
biochemical tests and public health thresholds, consult the latest literature or seek
specialist advice.
228
Appendix 5 – Measures of the public health significance of micronutrient deficiencies
Recommended Definition of a public health problem

Micronutrient defi- age group for
ciency indicator prevalence Severity Prevalence (%)
surveys
Vitamin A deficiency
Night blindness (XN) 24–71 months Mild 0≤1

Moderate 1≤5
Severe 5
Bitot’s spots (X1B) 6–71 months Not specified >0.5
Corneal xerosis/ulcer- 6–71 months Not specified >0.01

ation/keratomalacia
(X2, X3A, X3B)
Corneal scars (XS) 6–71 months Not specified >0.05
Serum retinol 6–71 months Mild 2 ≤ 10

(≤ 0.7μmol/l)
Moderate 10 ≤ 20
Severe 20
Iodine deficiency
Goitre (visible and School-age children Mild 5.0–19.9

palpable)
Moderate 20.0–29.9
Severe 30.0
Median urinary iodine School-age children Excessive intake >300

concentration (mg/l)
Adequate intake 100–199
Mild deficiency 50–99
Moderate deficiency 20–49
Severe deficiency <20
Iron deficiency
Anaemia Women, children Low 5–20

(Non-pregnant women 6–59 months
haemoglobin <12.0g/ Medium 20–40
dl; children 6–59
High 40
months <11.0g/dl)
Beriberi
Clinical signs Whole population Mild 1 case and <1%
Moderate 1–4
Severe 5
229
Recommended Definition of a public health problem

Micronutrient defi- age group for
ciency indicator prevalence Severity Prevalence (%)
surveys
Dietary intake Whole population Mild 5
(<0.33mg/l,000kCal)
Moderate 5–19
Severe 20–49
Infant mortality Infants 2–5 Mild No increase in

months rates
Moderate Slight peak in
rates
Severe Marked peak in
rates
Pellagra
Clinical signs (derma- Whole population Mild ≥ 1 case and <1%

titis) in surveyed age or women >15
group years Moderate 1–4
Severe 5
Dietary intake of Whole population Mild 5–19

niacin equivalents or women >15
<5mg/day years Moderate 20–49
Severe 50
Scurvy
Clinical signs Whole population Mild 1 case and <1%
Moderate 1–4
Severe 5
230
Appendix 6 – Nutritional requirements
Appendix 6
Nutritional requirements
Use the following table for planning in the initial stage of a crisis. The minimum
nutrient requirements given in the table should be used to assess general rations.
They are not intended for assessing the adequacy of supplementary or therapeutic
care rations or for assessing rations for particular groups of people such as
individuals suffering from tuberculosis or people living with HIV.
Nutrient Minimum population requirements

Energy 2,100kCal
Protein 53g (10% of total energy)
Fat 40g (17% of total energy)
Vitamin A 550µg retinol activity equivalents (RTE)
Vitamin D 6.1µg
Vitamin E 8.0mg alpha-tocopherol equivalents (alpha TE)
Vitamin K 48.2µg
Vitamin B1 (thiamine) 1.1mg
Vitamin B2 (riboflavin) 1.1mg
Vitamin B3 (niacin) 13.8mg niacin equivalents (NE)
Vitamin B6 (pyridoxine) 1.2mg
Vitamin B12 (cobalamin) 2.2µg
Folate 363µg dietary folate equivalents (DFE)
Pantothenate 4.6mg
Vitamin C 41.6mg
Iron 32mg
Iodine 138µg
Zinc 12.4mg
Copper 1.1mg
Selenium 27.6µg
Calcium 989mg
Magnesium 201mg
Source: RNIs from FAO/WHO (2004), Vitamin and Mineral Requirements in Human Nutrition, 2nd edition,
were used for all vitamin and mineral requirement calculations except copper. Requirements for copper are
taken from WHO (1996), Trace Elements in Human Nutrition and Health.
These average population minimum requirements incorporate the requirements of

all age groups and both sexes. They are therefore not specific to any single age or
sex group and should not be used as requirements for an individual. They are based
on an assumed demographic profile, assumptions about the ambient temperature
231
and people’s activity levels. They also take into account the additional needs of
pregnant and breastfeeding women.
The requirements are expressed as reference nutrient intakes (RNI) for all nutrients
except energy and copper.
Updates and further research on macro- and micronutrients are available on
the Food and Agriculture Organization of the United Nations (FAO) and WHO
websites.
Adjust the population energy requirements (up or down) for the following:
•• the demographic structure of the population, in particular the percentage of

those under five years, percentage of females and older people, adolescents;
•• mean adult weights and actual, usual or desirable body weights;
•• activity levels to maintain productive life (requirements will increase if
activity levels exceed “light”, or 1.6 x basal metabolic rate);
•• average ambient temperature, and shelter and clothing capacities
(requirements will increase if the mean ambient temperature is less
than 20°C);
•• the nutritional and health status of the population (requirements will
increase if the population is malnourished and has extra requirements for
catch-up growth. HIV prevalence may affect average population require-
ments. Adjust general rations to meet these needs, based on a context
analysis and current international recommendations).
For guidance on calculating adjustments, ⊕ see UNHCR, UNICEF, WFP and WHO
(2002), Food and Nutrition Needs in Emergencies and WFP (2001), Food and Nutrition
Handbook for guidance on calculating adjustments.
If it is not possible to gain this kind of information from assessments, use the
figures in the table above as the minimum requirements.
For understanding the population structure, broken down by sex, age and other
criteria as needed, use national baseline data or refer to World Population
Prospects: https://esa.un.org/unpd/wpp/
232

General
Emergency Preparedness and Response Package. WFP, 2012. http://documents.wfp.org
Harvey, P. Proudlock, K. Clay, E. Riley, B. Jaspars, S. Food Aid and Food Assistance
in Emergencies and Transitional Contexts: A Review of Current Thinking. Humanitarian
Policy Group, 2010.
Humanitarian inclusion standards for older people and people with disabilities.
Age and Disability Consortium, 2018. www.refworld.org
IASC Framework on Durable Solutions for Internally Displaced Persons. IASC, 2010.
Lahn, G. Grafham, O. Heat, Light and Power for Refugees: Saving Lives, Reducing Costs.
Chatham House, 2015. https://www.chathamhouse.org
www.seepnetwork.org
Minimum Standards for Child Protection in Humanitarian Assistance. CPWG, 2016.
http://cpwg.net
Minimum Standards for Education: Preparedness, Recovery and Response. The Inter-
Agency Network for Education in Emergencies [INEE], 2010. www.ineesite.org
Pejic, J. The Right to Food in Situations of Armed Conflict: The Legal Framework.
International Review of the Red Cross, 2001. https://www.icrc.org
Safe Fuel and Energy Issues: Food Security and Nutrition. Safe Fuel and Energy, 2014.
www.safefuelandenergy.org
The Right to Adequate Food (Article 11: 12/05/99. E/C 12/1999/5, CESCR General
Comment 12). United Nations Economic and Social Council, 1999. www.ohchr.org
The Sendai Framework for Disaster Risk Reduction. UNISDR. https://www.unisdr.org
Assessment
RAM-OP: Rapid Assessment Method for Older People. www.helpage.org
SMART (Standardized Monitoring and Assessments of Relief and Transition) Guidelines
and Methodology. SMART. http://smartmethodology.org
Nutrition
Castleman, T. Seumo-Fasso, E. Cogill, B. Food and Nutrition Implications of Antiretroviral
Therapy in Resource Limited Settings, Food and Nutrition Technical Assistance, technical
note no. 7. FANTA/AED, 2004.
233
Chastre, C. Duffield, A. Kindness, H. LeJeane, S. Taylor, A. The Minimum Cost of Diet:

Findings from piloting a new methodology in Four Study Locations. Save the Children
UK, 2007. https://resourcecentre.savethechildren.net
Codex Alimentarius. Standards, Guidelines and Advisory Texts. FAO and WHO. www.fao.org
Food and Nutritional Needs in Emergencies. WHO, UNHCR, UN Children’s Fund, WFP,
2004. www.who.int
International Code of Marketing of Breast-Milk Substitutes. WHO, 1981. www.who.int
Management of acute malnutrition

Black, RE. Allen, LH. Bhutta, ZA. Caulfield, LE. de Onis, M. Ezzati, M. Mathers, C.
Rivera, J. Maternal and child undernutrition: global and regional exposures and health
consequences. The Lancet, vol. 371, no. 9608, 2008, pp. 243–260. https://doi.org
Participatory methodologies
Bonino, F. What Makes Feedback Mechanisms Work. ALNAP, 2014.

Child Growth Standards and the Identification of Severe Acute Malnutrition in Infants
and Children. WHO, 2009.
Early Childhood Development in Emergencies: Integrated Programme Guide. UNICEF,
2014. https://www.unicef.org
Integrating Early Childhood Development Activities into Nutrition Programmes in
Emergencies: Why, What and How? UNICEF & WHO Joint statement, 2010.
www.who.int
Operational Guidance on Infant and Young Child Feeding in Emergencies. IFE Core Group,
2017. https://www.ennonline.net
Children
Growth reference for school-aged children and adolescents. WHO, 2007. www.who.int
Food security
Coping Strategies Index: CSI Field Methods Manual. CARE, 2008.
Caccavale, O. Flämig, T. Collecting Prices for Food Security Programming. World Food
Programme, 2015. http://documents.wfp.org
Coates, J. Swindale, A. Bilinsky, P. Household Food Insecurity Access Scale (HFIAS) for
Measurement of Food Access, Indicator Guide, Version 3. FANTA, 2007.
Food Safety and Quality. FAO and WHO. www.fao.org
Food Security Cluster Urban Group Tools and Pilot Projects. Food Security Cluster.
http://fscluster.org
Food Security Cluster Core Indicator Handbook. Food Security Cluster. http://fscluster.org
Humanitarian, Impact areas. Global Alliance for Clean Cookstoves, 2018.
http://cleancookstoves.org
234
Integrated Food Security Phase Classification (IPC) 2018 – Technical Manual Version 3.
IPC Global Partners, 2018.
Save Food: Global Initiative on Food Loss and Waste Reduction – Extent, Causes and
Reduction. FAO and WHO. http://www.fao.org
Swindale, A. Bilinsky, P. Household Dietary Diversity Score (HDDS) for Measurement of
Household Food Access: Indicator Guide, Version 2. FANTA, 2006.
Technical Guidance Note: Food Consumption Score Nutritional Quality Analysis (FCS-N).
WFP, 2015. https://www.wfp.org
Tier ranking from the IWA interim ISO standards. Global Alliance for Clean Cookstoves.
http://cleancookstoves.org
Voluntary Guidelines to Support the Progressive Realization of the Right to Adequate
Food in the Context of National Food Security. Committee on World Food Security,
2005.
Food assistance
Guide to Personal Data Protection and Privacy. WFP, 2016. https://docs.wfp.org
Integrated Protection and Food Assistance Programming. ECHO-DG, Final Draft.
https://reliefweb.int
NutVal 2006 version 2.2: The planning, calculation, and monitoring application for food
assistance programme. UNHCR, WFP, 2006. www.nutval.net
Protection in Practice: Food Assistance with Safety and Dignity. UN-WFP, 2013.
https://reliefweb.int
Revolution : From Food Aid to Food Assistance – Innovations in Overcoming Hunger.
WFP, 2010. https://documents.wfp.org
Seed interventions
Seed System Security Assessment (SSSA). CIAT and DEV, 2012. https://seedsystem.org
Seeds in Emergencies: A Technical Handbook. FAO, 2010. www.fao.org
Markets and cash-based assistance (CBA)

CaLP CBA quality toolbox: pqtoolbox.cashlearning.org
Cash and Vouchers Manual. WFP, 2014. https://www.wfp.org
E-Transfers in Emergencies: Implementation Support Guidelines. CaLP, 2013.
Emerging Good Practice in the Use of Fresh Food Vouchers. ACF International, 2012.
www.actionagainsthunger.org
Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian Action.
IASC, 2015. www.gbvguidelines.org
Gender
Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian Action.
IASC, 2015. www.gbvguidelines.org
235
Researching Violence Against Women: A Practical Guide for Researchers and Activists. WHO
and Program for Appropriate Technology in Health (PATH), 2005. www.who.int

Including Children with Disabilities in Humanitarian Action, Nutrition booklet. UNICEF.
http://training.unicef.org
Module on Child Functioning and Disability. UNICEF, 2018. https://data.unicef.org
Livelihoods
CLARA: Cohort Livelihoods and Risk Analysis. Women’s Refugee Commission, 2016.
https://www.womensrefugeecommission.org
Sustainable Livelihoods Guidance Sheets. DFID, 2000. http://www.livelihoodscentre.org
Environment
Flash Environmental Assessment Tool. UNOCHA. www.eecentre.org
Handbook on Safe Access to Firewood and Alternative Energy. WFP, 2012.
Integrated Food Security Phase Classification (IPC) 2018 – Technical Manual Version 3.
IPC Global Partners, 2018.
Lahn, G. Grafham, O. Heat, Light and Power for Refugees: Saving Lives, Reducing Costs.
Chatham House, 2015. https://www.chathamhouse.org
Moving Energy Initiative. Chatham House, 2018. https://mei.chathamhouse.org
Further reading
236
further reading
Further Reading
Initial assessment
Joint Assessment Mission (JAM): Guidelines Second Edition. UNHCR/WFP, 2009.
Multi-sector Initial Rapid Assessment (MIRA) Tool. IASC, 2015.
Technical Guidance for the Joint Approach to Nutrition and Food Security Assessment
(JANFSA). WFP and UNICEF, 2016.
Food security assessments

Alternative Sampling Designs for Emergency Settings: A Guide for Survey Planning,
Data Collection and Analysis. FANTA, 2009. www.fantaproject.org/publications/
asg2009.shtml
Comparing Household Food Consumption Indicators to Inform Acute Food Insecurity
Phase Classification. FANTA, 2015. https://www.fantaproject.org/sites/default/
files/resources/HFCIS-report-Dec2015.pdf
Crop and Food Security Assessment Mission (CFSAM) Guidelines. FAO and WFP, 2009. www.
wfp.org/food-security/assessments/crop-food-security-assessment-mission
Comprehensive Food Security and Vulnerability Analysis (CFSVA) Guidelines. WFP, 2009.
Emergency Food Security Assessment Handbook (EFSA) – second edition. WFP, 2009.
Household Livelihood Security Assessments: A Toolkit for Practitioners. CARE, 2002.
Vulnerability and Capacity Assessment Guide. IFRC. www.ifrc.org/vca
The Household Economy Approach: A Guide for Programme Planners and Policy-makers.
Save the Children, 2008.
Seed security assessment

Longley, C. Dominguez, C. Saide, M.A. Leonardo, W.J. Do Farmers Need Relief Seed?
A Methodology for Assessing Seed Systems. Disasters, NCBI, 2002.
Sperling, L. When Disaster Strikes: A guide to Assessing Seed System Security.
International Center for Tropical Agriculture, 2008.
Livelihood assessment
Jaspers, S. Shoham, J. A Critical Review of Approaches to Assessing and Monitoring
Livelihoods in Situations of Chronic Conflict and Political Instability. ODi, 2002.
Matrix on Agency Roles and Responsibilities for Ensuring a Coordinated, Multi-Sectoral
Fuel Strategy in Humanitarian Settings. Version 1.1. Task Force on Safe Access to
Firewood and Alternative Energy in Humanitarian Settings. IASC, 2009.
Markets
Adams, L. Learning from Cash Responses to the Tsunami: Final Report, HPG back-
ground paper. HPG, 2007. https://www.odi.org/sites/odi.org.uk/files/odi-assets/
publications-opinion-files/4860.pdf
F1
Cash, Local Purchase, and/or Imported Food Aid? Market Information and Food Insecurity
Response Analysis. CARE, 2008.
Creti, P. Jaspars, S. Cash Transfer Programming in Emergencies. Oxfam GB, 2006.
Delivering Money: Cash Transfer Mechanisms in Emergencies. Save the Children UK,
Oxfam GB and British Red Cross, with support from ECHO, CaLP, 2010.
Harvey, P. Cash and Vouchers in Emergencies, HPG background paper. ODI, 2005.
Implementing Cash-Based Interventions: A guide for aid workers. Action contre la
faim, 2007.
Minimum Standard for Market Analysis (MISMA). CaLP, 2013.
Mike, A. Emergency Market Mapping and Analysis (EMMA) toolkit. Oxfam GB, 2010.
Multi-Sector Initial Rapid Assessments (MIRA) Guidance. IASC, 2015.
Food consumption
Food Consumption Analysis: Calculation and Use of the Food Consumption Score
in Food Security Analysis. Technical Guidance Sheet. WFP, 2008. www.wfp.org/
content/technical-guidance-sheet-food-consumption-analysis-calculation-
and-use-food-consumption-score-food-s
Household Dietary Diversity Score (HDDS). Food and Nutrition Technical Assistance
Project, 2006.
Reference Nutrient Intake (RNI) publications. WHO. www.who.int/nutrition/publi-
cations/nutrient/en/ and www.who.int/elena/nutrient/en/
Participatory methodologies
Climate Vulnerability and Capacity Analysis Handbook. CARE, 2009.
Climate Change and Environmental Degradation Risk and Adaptation Assessment
(CEDRA). Tearfund, 2009.
How to do a Vulnerability and Capacity Assessment (VCA), a step-by-step guide for Red
Cross and Red Crescent Staff and Volunteers. IFRC, 2007.
Participatory Vulnerability Analysis. ActionAid, 2004.
Nutrition and food security information systems

Famine Early Warning Systems Network. USAID. www.fews.net
Food Insecurity and Vulnerability Information and Mapping Systems (FIVIMS). FIVIMS,
2013. www.fao.org/3/a-x8346e.pdf
Global Information and Early Warning System on Food and Agriculture. FAO. www.fao.
org/ES/giews/english/index.htm
Integrated Food Security Phase Classification, Technical Manual. Version 1.1. IPC Global
partners and FAO, 2008.h www.fao.org/docrep/010/i0275e/i0275e.pdf
Shoham, J. Watson, F. Dolan, C. The Use of Nutrition Indicators in Surveillance Systems,
Technical paper 2. ODI, 2001. https://www.odi.org/sites/odi.org.uk/files/odi-as-
sets/publications-opinion-files/3970.pdf
F2
further reading
Anthropometric assessment
A Manual: Measuring and Interpreting Malnutrition and Mortality. Centers for Disease
Control and Prevention and WFP, 2005.
Assessment of Adult Undernutrition in Emergencies. Report of an SCN working group on
emergencies special meeting, pp. 49–51. UN ACC Sub Committee on Nutrition, 2001.
Collins, S. Duffield, A. Myatt, M. Adults: Assessment of Nutritional Status in
Emergency-Affected Populations. ACC, Sub-Committee on Nutrition, 2000.
https://www.unscn.org/web/archives_resources/files/AdultsSup.pdf
Emergency Nutrition Assessment and Guidance for Field Workers. Save the Children
UK, 2004.
Young, H. Jaspars, S. The Meaning and Measurement of Acute Malnutrition in
Emergencies: A Primer for Decision Makers. HPN, 2006. https://odihpn.org/
resources/the-meaning-and-measurement-of-acute-malnutrition-in-emergen-
cies-a-primer-for-decision-makers/
Micronutrient assessment
Gorstein, J. Sullivan, K.M. Parvanta, I. Begin, F. Indicators and Methods for Cross
Sectional Surveys of Vitamin and Mineral Status of Populations. Micronutrient
Initiative and CDC, 2007. www.who.int/vmnis/toolkit/mcn-micronutrient-
surveys.pdf
Infant and young child feeding assessment

Infant and young child feeding practices, Collecting and Using Data: A Step-by-Step
Guide. CARE, 2010. www.ennonline.net/resources

Baby Friendly Spaces Manual, Chapter 4 Feeding of the Non-Breastfed Infant. ACF
International, 2014.
ECHO Infant and Young Children Feeding in Emergencies: Guidance for Programming.
h t t p s : //e c . e u r o p a . e u /e c h o / f i l e s /m e d i a /p u b l i c a t i o n s / 2 014 / t o o l k i t _
nutrition_en.pdf
Global Strategy for Infant and Young Child Feeding. UNICEF and WHO, 2003.
Guidance on Infant Feeding and HIV in the Context of Refugees and Displaced Populations.
UNHCR, 2009. www.ibfan.org/art/367-6.pdf
Guiding Principles for Feeding Infants and Young Children during Emergencies.
WHO, 2004.
Global Nutrition Targets 2025, Breastfeeding Policy Brief. WHO/UNICEF, 2014
w w w.who.int /nut r it ion /public at ions/glob alt a r get s2025_polic y br ief_
breastfeeding/en/
HIV and Infant Feeding: Principles and Recommendations for Infant Feeding in the
Context of HIV and a Summary of Evidence. WHO, 2010.
IFE Module 1: Orientation package on IFE. IFE Core Group and collaborators, 2009.
www.ennonline.net/ifemodule1
F3
Indicators for Assessing Infant and Young Child Feeding Practices. USAID, AED, FANTA,
IFPRI, UNICEF and WHO, 2007.
Infant and Young Child Feeding Practices: Standard Operating Procedures for the
Handling of Breast Milk Substitutes in Refugee Children 0–23 months and the Annex.
UNHCR, 2015. www.unhcr.org/55c474859.pdf
Module 2 on Infant Feeding in Emergencies for health and nutrition workers in emergency
situations. IFE Core Group and collaborators, 2007. www.ennonline.net/ifemodule2
Protecting infants in emergencies, Information for the media. IFE Core Group, 2009.
www.ennonline.net//ifecoregroup
UNICEF Programming Guide on Infant and Young Child Feeding 2011. www.unicef.org/
nutrition/files/Final_IYCF_programming_guide_2011.pdf
General food security

Barrett, C. Maxwell, D. Food Aid After Fifty Years: Recasting Its Role. Routledge,
New York, 2005. https://www.gordon.edu/ace/pdf/F06F&E4748BR5McNamara.pdf
Food and Nutrition Needs in Emergencies. UNHCR, UNICEF, WFP and WHO, 2002.
Food Assistance Manual Series, General Distribution. World Vision International, 2017.
Guidelines for Gender-based Violence Interventions in Humanitarian Settings – Focusing
on Prevention of and Response to Sexual Violence in Emergencies, Chapters 1–4, Action
Sheet 6.1 Food Security and Nutrition. IASC, 2005.
Minimum Standards for Child Protection in Humanitarian Action. Alliance for
Child Protection in Humanitarian Action, 2012. https://resourcecen-
t r e.savethechildren.net /librar y/minimum-st andards-child-protection-
humanitarian-action
Maxwell, D. Sadler, K. Sim, A. Mutonyi, M. Egan, R. Webster, M. Emergency Food
Security Interventions, Good Practice Review #10. Relief and Rehabilitation Network,
ODI, 2008. https://www.ennonline.net/attachments/882/hpn-emergency-
food-security-interventions.pdf
The Right to Adequate Food: Fact Sheet No.34. OHCHR and FAO, 2010. www.ohchr.
org/Documents/Publications/FactSheet34en.pdf
Targeting and food distribution

Catalogue and Standard Operating Procedures. UN Humanitarian Response Depot,
2010. www.unhrd.org
Food Quality Control. WFP, 2010. http://foodqualityandsafety.wfp.org/
Food Storage Manual. Natural Resources Institute and WFP, 2003.
Food Assistance Main Manual, Third edition. World Vision International, 2017.
Food Assistance in the Context of HIV: Ration Design Guide. WFP, 2008.
Food Resource Management Handbook. CARE.
Jaspars, S. Young, H. General Food Distribution in Emergencies: From Nutritional
Needs to Political Priorities, Good Practice Review 3. Relief and Rehabilitation
Network, ODI, 1995.
F4
further reading
Logistics Operational Guide. WFP, Logistics Cluster, 2010.

School Feeding Quality Standards. WFP, 2009.
Targeting in Emergencies. WFP, 2006.
UNHCR Handbook for Registration. UNHCR, 2003.
Seed interventions
Seed Vouchers and Fairs: A Manual for Seed-Based Agricultural Recovery in Africa.
CRS with ODI and the International Crops Research Institute for the Semi-Arid
Tropics, 2002.
Sperling, L. Remington, T. Haugen, JM. Seed Aid for Seed Security: Advice for
Practitioners, Practice Briefs 1-10. International Centre for Tropical Agriculture and
CRS, 2006.
General emergency nutrition manuals

A Toolkit for Addressing Nutrition in Emergency Situations. IASC, 2008.
Food and Nutrition Needs in Emergencies. UNHCR, UNICEF, WFP and WHO, 2002.
Food and Nutrition Handbook. WFP, 2001.
Guidelines for Selective Feeding the Management of Malnutrition in Emergencies.
UNHCR and WFP, 2009.
Harmonised Training Package (HTP). IASC Nutrition Cluster’s Capacity Development
Working Group, 2006.
Khara, T. Dolan, C. Technical Briefing Paper: The Relationship between Wasting and
Stunting, Policy, Programming and Research Implications. ENN, 2014.
Moderate Acute Malnutrition: A Decision Tool for Emergencies. GNC MAM Task
Force, 2014.
Prudhon, C. Assessment and Treatment of Malnutrition in Emergency Situations.
ACF, 2002.
The Management of Nutrition in Major Emergencies. WHO, 2000.
Vulnerable people
Addressing the Nutritional Needs of Older People in Emergency Situations in Africa: Ideas
for Action. HelpAge International, 2001. http://nutritioncluster.net/wp-content/
uploads/sites/4/2015/06/Nutrition-FINAL.pdf
Food Assistance Programming in the Context of HIV. FANTA and WFP, 2007.
Living Well with HIV and AIDS. A Manual on Nutritional Care and Support for People
Living with HIV and AIDS. FAO and WHO, 2002.
Older People in Disasters and Humanitarian Crisis. HelpAge and UNHCR, 2007.
Women, Girls, Boys and Men: Different Needs – Equal Opportunities. IASC, 2006.
Winstock, A. The Practical Management of Eating and Drinking Difficulties in Children.
Winslow Press, 1994.
F5
Management of acute malnutrition

Community Based Therapeutic Care (CTC): A Field Manual. VALID International, 2006.
Community-Based Management of Severe Acute Malnutrition. WHO, WFP, UNSCN and
UNICEF, 2007.
Integration of IYCF support into CMAM. ENN, IFE Core Group and collaborators, 2009.
www.ennonline.net/resources
MAMI Report, Technical Review: Current Evidence, Policies, Practices & Program
Outcomes. ENN, CIHD and ACF, 2010.
Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health
Workers. WHO, 1999.
Navarro-Colorado, C. Mason, F. Shoham, J. Measuring the Effectiveness of SFP in
Emergencies. HPN, 2008.
Navarro-Colorado, C. Shoham, J. Supplementary Feeding Minimum Reporting Package.
HPN, Forthcoming.
Training Guide for Community-based Management of Acute Malnutrition. FANTA, 2008.
Guiding Principles for the Use of Multiple Vitamin and Mineral Preparations in
Emergencies. WHO and UNICEF, 2007.
Iron Deficiency Anaemia: Assessment, Prevention and Control. A Guide for Program
Managers. UNICEF, UNU and WHO, 2001.
Pellagra and Its Prevention and Control in Major Emergencies. WHO, 2000.
Seal, A. Prudhon, C. Assessing Micronutrient Deficiencies in Emergencies: Current
Practice and Future Directions. UN Standing Committee on Nutrition, 2007. https://
www.ennonline.net/attachments/893/micronutrientssup.pdf
Scurvy and Its Prevention and Control in Major Emergencies. WHO, 1999.
Thiamine Deficiency and Its Prevention and Control in Major Emergencies. WHO, 1999.
Vitamin A Supplements: A Guide to Their Use in the Treatment and Prevention of Vitamin
A Deficiency and Xeropthalmia, Second Edition. WHO, 1997.
F6
Shelter and
Settlement
Humanitarian
Charter
Protection Core
Standard
Shelter and Settlement
Location
and Living Household Technical Security Environmental
Planning
settlement space items assistance of tenure sustainability
planning
Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 Standard 6 Standard 7
Planning Location and Living Household Technical Security Environmental

settlement space items assistance of tenure sustainability
planning
Appendix 1 Shelter and settlement assessment checklist

Appendix 2 Description of settlement senarios
Appendix 3 Additional characteristics of settlement senarios
Appendix 4 Assistance options
Appendix 5 Implementation options
Appendix 6 Potential assistance and implementation options connected to settlement scenarios (online)
238
Contents
Essential concepts in shelter and settlement................................................................. 240
Shelter and settlement standards:
1. Planning.............................................................................................................................. 246
2. Location and settlement planning............................................................................. 249
3. Living space....................................................................................................................... 254
4. Household items.............................................................................................................. 258
5. Technical assistance....................................................................................................... 262
6. Security of tenure............................................................................................................ 266
7. Environmental sustainability....................................................................................... 270
Appendix 1: Shelter and settlement assessment checklist....................................... 274
Appendix 2: Description of settlement scenarios......................................................... 278
Appendix 3: Additional characteristics of settlement scenarios............................. 280
Appendix 4: Assistance options.......................................................................................... 282
Appendix 5: Implementation option................................................................................... 285
Appendix 6: Potential assistance and implementation options connected
to settlement scenarios (online)
239
SHELTER AND SETTLEMENT
Essential concepts in shelter

and settlement
Everyone has the right to adequate housing
The Sphere Minimum Standards for Shelter and Settlement are a practical expres-
sion of the right to adequate housing in humanitarian contexts. The standards
are grounded in the beliefs, principles, duties and broader rights declared in the
Humanitarian Charter. These include the right to life with dignity, the right to
protection and security, and the right to receive humanitarian assistance on the
basis of need.
A list of the key legal and policy documents that inform the Humanitarian Charter
is in Annex 1 with explanatory comments for humanitarian workers.
Shelters and settlements are inter-related and need to be considered as a
whole. “Shelter” is the household living space, including the items necessary to
support daily activities. “Settlement” is the wider locations where people and
community live.
Shelter and settlement responses aim to provide a safe living environment

Timely shelter and settlements support can save lives in the initial stages of a
crisis. In addition to providing protection from weather, shelter is necessary to
promote health, support family and community life, and provide dignity, security
and access to livelihoods ⊕ see Figure 8 below.
The average time that people are displaced has continued to increase over the
years. With displacement lasting years or even decades, the location of the
shelters and settlement sites, as well as the planning of neighbourhoods and
communities where shelters are situated, are important in supporting the dignity
and the recovery of people affected by crisis.
Shelter and settlement assistance should support and draw on the existing
strengths of affected households, communities, civil society and government.
This increases the chance of developing localised strategies that encourage
self-sufficiency and self-management by the affected people. A sense of safety,
community and social cohesion are essential to begin the process of recovery.
Shelter and settlement response options are not limited to delivering hardware
and materials or constructing a shelter. Response options also include providing
support to secure land and obtain shelter, housing or household items. This
includes technical assistance and quality assurance, which can empower and
mobilise an affected population to build back better and more safely. Knowing the
national legal framework for land and property is essential. An understanding of
the national refugee legislation and associated procedures for determining status
is also important.
240
Essential concepts in shelter and settlement
PROTECTION FROM
THE WEATHER
LIVELIHOODS HEALTH
Work opportunities are Shelter protects people
close to the shelter from falling ill
WHAT
SECURITY SUPPORT FOR FAMILY
People can feel safe from
SHELTER AND COMMUNITY LIFE
the outside world PROVIDES Shelter provides a safe
place for families to live
and engage with others
DIGNITY
Family members have
privacy within their home
What shelter provides (Figure 8)

Some of the functions of appropriate emergency shelter. Shelter programmes should support families to meet
these needs.
Regardless of the form of support provided, it is important to always respect

existing community structures and promote social cohesion.
Each household and community will require different levels and types of support.
Security of tenure and adequate civil status documentation is a basic requirement
to access safe shelter. However, in conflict settings or where there are unresolved
issues related to land tenure, shelter support may be particularly complex ⊕ see
Shelter and settlement standard 6: Security of tenure.
Increasingly, there is a need to consider long-term displacement and recovery
in settlement planning. Displacement can put pressure on existing – often
limited – resources and foster tensions with the surrounding host community.
Quality programming includes understanding, preventing and mitigating negative
environmental impacts. If environmental issues are not taken into account,
shelter and settlement programmes may ultimately be inefficient, since short-
term outcomes can cause new problems requiring further investment ⊕ see Shelter
and settlement standard 7: Environmental sustainability.
Shelter and settlement responses in urban settings require specific expertise

Assisting people in urban areas can be complicated because of the high popu-
lation density, infrastructure needs, government regulations and the social
diversity within the community. During and after a crisis, communicating
with and assisting highly mobile people is difficult, especially when it comes
to finding enough living space. If technically complex infrastructure (such as
high-rise buildings) is affected, humanitarian organisations will also need to
241
work with complex tenancy arrangements involving multiple owners, renters

or informal settlers.
Working in urban contexts requires expertise in urban planning and design and
knowledge of rights, regulations, laws and policies relating to housing, land and
property. A strong understanding of local housing and financial markets is crucial.
Be prepared to engage with civil society and the private sector. The private sector
can play a role in delivering sustainable market-based solutions. The responses
should build on local norms and services and avoid creating parallel structures.
Developing a holistic response at settlement, neighbourhood or area level is more
likely to provide a sustainable contribution to the well-being of affected popula-
tions in urban areas ⊕ see Delivering assistance through markets.
Various post-crisis settlement scenarios need to be considered

Where and how affected people find shelter will vary depending on their ability
to remain in place or their need to move away. A systematic consideration of the
post-crisis context is the first step in planning options for shelter and settlement
assistance. It is important to understand the different approaches that may be
appropriate for people who are displaced, directly affected but not displaced, or
indirectly affected ⊕ see Figure 9 below.
If conditions permit, people may choose to remain in their place of origin as
owner-occupier or in rented or informally occupied accommodation or land.
Support to non-displaced households could include repair or reconstruction of
existing dwellings.
Displaced populations may disperse locally, to other locations within their
country of residence, or across international borders. In such situations they are
likely to rent accommodation, self-settle or be hosted by others. Some displaced
households may choose to gather in collective accommodation or an planned
settlement, or to shelter in an unplanned settlement.
An understanding of the crisis through these settlement scenarios will help in
planning assistance strategies. This includes selecting the most effective and
appropriate type of assistance according to specific categories of the affected
populations, and selecting ways of delivering the assistance. It should contribute
to an incremental recovery, ideally reaching a durable solution. The standards and
appendices in this chapter follow this logic and are meant to be used together
⊕ see Appendix 2: Description of settlement scenarios and Appendix 3: Additional
characteristics of settlement scenarios.

The Minimum Standards in this chapter reflect the core content of the right
to adequate shelter and contribute to the progressive realisation of this
right globally.
The right to adequate shelter is linked to the rights to water and sanitation, food
and health. Progress in achieving the Sphere Minimum Standards in one area influ-
ences progress in other areas. For a response to be effective, close coordination and
242
Pre-crisis context of settled population
Crisis impacts where people live
Post-crisis settlement scenarios
NON-DISPLACED DISPLACED INDIRECTLY AFFECTED

POPULATION POPULATION POPULATION
DISPERSED
1. Owner occupied 1. Rental arrangement 1. Host population
accommodation or land
2. Hosted arrangement
2. Rental accommodation 3. Spontaneous arrangement
or land
3. Informally occupied COMMUNAL

accommodation or land
4. Collective accommodation
5. Planned settlement
6. Unplanned settlement
Selection of assistance options and implementation
DURABLE SOLUTIONS
Reconstruction
Resettlement
Reintegration
Post-crisis settlement scenarios (Figure 9)
243
collaboration are required with other sectors. Coordination with local authorities
and other responding agencies helps ensure that needs are met, that efforts are not
duplicated and that the quality of food security and nutrition responses is optimised.
Cross-references throughout the Handbook suggest some potential linkages.
For example, adequate water supply and sanitation facilities in settlements are
necessary to ensure the health and dignity of the affected population. Essential
cooking and eating utensils and fuel for cooking enable people to use food assistance
and meet nutritional requirements.
Where national standards are lower than the Sphere Minimum Standards, humanitarian
organisations should work with the government to progressively raise them.
International law specifically protects the right to adequate shelter

The right to access adequate housing is protected by international law. It is the right
to live somewhere in security, peace and dignity. This right contains freedoms such as
the right to choose one’s residence and entitlements such as security of tenure.
It enshrines protection principles such as protection from forced eviction. States
are obliged to ensure this right when individuals or groups, including refugees and
internally displaced persons, are unable to access adequate housing, including in
crises ⊕ see Annex 1: Legal foundation to Sphere.
The concept of “adequacy” means that housing is more than four walls and a
roof. It underlines the importance of including a settlement lens, cultural identity
and the availability of services in a shelter response. “Adequate” housing or other
forms of shelter should provide security of tenure and be:
•• affordable, allowing the household to attain other essential goods and

services to live in dignity;
•• habitable, providing physical safety, protected and adequate living space,
access to safe drinking water, adequate water, sanitation and hygiene
(WASH) facilities, and food preparation and storage;
•• culturally acceptable;
•• accessible and usable, including for persons facing mobility barriers; and
•• located to provide access to livelihoods opportunities and essential
community services.

Crises can worsen pre-existing inequalities. Therefore, it is important to offer
impartial and context-sensitive assistance, in particular to those who have the
least capacity to recover from a crisis by themselves ⊕ see Protection Principle 2.
Some people may have difficulties accessing shelter and settlement assistance,
due to physical, cultural, economic and social barriers. In understanding and
responding to these, pay attention to the following:
•• The legal status of individuals (for example, refugee, internally displaced,

stateless, migrant, asylum seeker, homeless or landless, and others deprived
of civil liberties and access to public services or social safety nets); and
244
•• People facing unique protection risks and groups at particular risk of

discrimination and social exclusion due to:
–– their ethnicity, nationality, caste, indigenous group, or religious or
political affiliation;
–– their tenure situation, displacement status, informal settler status or
renter status;
–– the location of dwellings that are difficult to access, in hazardous areas,
insecure areas, urban settlements or informal settlements; and
–– their vulnerability and status within society ⊕ see What is Sphere and
Protection Principles.
Aid workers should be trained on child safeguarding and know how to use referral
systems for suspected cases of violence, abuse or exploitation, including of children.
Humanitarian Standard should be respected as a foundation for providing an
accountable shelter and settlement programme.
245
1. Planning
Planning is crucial for optimal response outcomes at regional, national, agency or
community levels. Understanding the pre- and post-crisis context allows an
assessment of both the direct and the indirect impact of the crisis on people’s
living conditions and any social, economic and political consequences. Identifying
needs and then developing appropriate response options, is the basis for a well-
planned and coordinated shelter and settlement response.
Shelter and settlement standard 1:

Planning
Shelter and settlement interventions are well planned and coordinated
to contribute to the safety and well-being of affected people and
promote recovery.
Key actions
1.
1 Work with the affected population as well as national and local authorities to
assess the shelter and settlement needs and capacities.
•• Assess changes from the pre-crisis context, identify immediate needs and
capacities for the displaced and non-displaced populations, and consider any
specific needs of at-risk groups.
•• Identify the availability of habitable or occupiable land, buildings, apartments
and rooms within the local housing and land rental markets.
2.
2 Work with stakeholders to identify the most effective and appropriate
assistance options and how to provide these.
3.
3 Develop a shelter and settlement plan in coordination with relevant authorities
and the affected communities.
•• Offer assistance tailored to the needs and preference of the affected population
and authorities.
•• Optimise cost-efficiency, technical quality, speed and timing, scale of
implementation and replicability.
Key indicators
The shelter and settlement plan provides for the essential needs of the target
population and is agreed with the population and relevant authorities
Percentage of affected people indicating that shelter and settlement

assistance reflects their needs and priorities and contributes to a more
durable solution
246
Planning
Guidance notes
Assessment: During assessment, review changes in the shelter and settlement
conditions post-crisis and include possible protection risks from the outset. These
may include perceptions of the host community, risks associated with access to
the settlement, safe access to services or risks of expulsion.
Consider the direct and indirect impact of the crisis on people’s living conditions,
including social, economic and political consequences.
Crisis affects people in different ways, so different people will have different
shelter and settlement needs. Work with groups who may face specific barriers
to access shelter, such as persons with disabilities, female-headed house-
holds, older people or ethnic and linguistic minorities ⊕ see Appendix 1: Shelter
and settlement assessment checklist, Protection Principle 2 and Core Humanitarian
Assistance and implementation options: Select the most effective options
based on context, capacity, resources available, the settlement scenario and
the phase of the response. Other factors to consider include location, housing
type (including local construction techniques), tenure, and market and legal
frameworks. Prioritise support for people’s return to their original dwelling
(or site of their dwelling) where possible. Assist those who are unable or unwilling to
return to their original dwellings to access options tailored to their needs ⊕ see
Appendices 2 to 6.
Define a timeline to meet immediate needs, considering efficiency, technical
quality, scale of implementation, capacities on the ground and replicability.
Explore options to increase communities’ long-term recovery and resilience to
future crises.
Consider different ways to deliver the chosen options, including a combination of:
•• financial support;
•• in-kind material assistance;
•• contracting works/commissioned labour;
•• technical assistance/quality assurance support; and
•• capacity building.
Review and adjust the combination of options over time as the situation changes.
Displaced people: As well as having immediate needs for shelter, displaced people
also require specific support to make informed decisions about shelter solutions
available to them. Examples of support include information about whether and
when they will return home, how to integrate at the place of displacement or
whether to resettle at a third location.
Non-displaced households will need support to return to their original living
conditions and should receive appropriate shelter assistance. If reconstruction
will take a long time or people are not safe, explore temporary options such as
247
host family assistance, rental assistance, or temporary or transitional shelter.

If the crisis has changed the security and safety environment, relocation might
be necessary.
Host communities also experience consequences of a crisis, as they share their
public and private space. This includes sharing services such as health centres or
schools, or acting as a host family. There may be real or perceived competition with
displaced people for jobs, services, infrastructure and resources. Solutions need
to consider equitable and targeted support that does not create additional risks or
threats in the community ⊕ see Protection Principle 1.
Market analysis: Understanding the surrounding markets at local, national and
regional level is critical for a good quality shelter response. It will inform choices
on shelter options and will also capture rent and other settlement-related service
information ⊕ see Delivering assistance through markets, MISMA Handbook and MERS
Handbook.
Debris removal: Initiate debris management immediately after the crisis. Debris
can be reused, recycled or identified for separation, collection and/or treatment.
It may provide opportunities for cash-for-work programmes. Key issues include
the presence of human bodies, structurally dangerous locations and hazardous
materials. Removal of debris may require specialised expertise and equipment, so
must be planned with other sector specialists ⊕ see Shelter and settlement standard 7:
Environmental sustainability, Health standards and WASH standards.
Livelihood opportunities: The livelihoods that people engaged in before the crisis,
and the opportunities existing after the crisis, are relevant in determining settle-
ment options. Land availability, safe access for cultivation and grazing, access to
markets and access to other employment opportunities can affect where people
choose to live, even temporarily ⊕ see Food security and nutrition – Livelihoods
standards 7.1 and 7.2, LEGS Handbook and MERS Handbook.
Return: Returning to their own land and dwellings is a major goal for most
crisis-affected people. Affected people should be able to determine the need for
repairing their dwellings or upgrading their shelter. Return can support communal
coping strategies and retain established settlement patterns and infrastructure.
The repair or reconstruction of communal infrastructure such as schools, water
systems, clinics or markets is also important to enable displaced people to return.
Some circumstances may prevent or delay return, such as security concerns,
armed forces occupying the property or land, continuing violent conflict, ethnic
or religious tension, fear of persecution, or landmines and unexploded ordnance.
Inadequate or discriminatory land and property legislation, or customary proce-
dures may prevent female-headed households, those widowed or orphaned by the
crisis, or persons with disabilities from returning. Displaced populations who may
not have the ability to undertake reconstruction activities may also be discouraged
or prevented from returning.
248
Location and settlement planning
2. Location and settlement planning

Location and settlement planning should promote safe, acceptable and accessible
living spaces that offer access to basic services, livelihoods and opportunities to
connect to a broader network.

Shelters and settlements are located in safe and secure areas, offering
adequate space and access to essential services and livelihoods.
Key actions
1.
1 Work within existing planning processes and regulations and agree terms
with host communities and relevant authorities.
•• Locate any new settlements a safe distance from actual or potential threats
and minimise risks from existing hazards.
•• Consider the expected lifespan of the settlement to determine what
essential services may need to be expanded or developed.
2.
2 Involve diverse stakeholders, including groups within the affected popula-
tion, in site selection and settlement planning.
•• Identify factors that could affect the location or site layout, considering sex, age,
disability, ethnic or linguistic identity, and gender roles and responsibilities.
•• In urban contexts, work through a geographically defined, area-based
approach to better understand community dynamics.
3.
3 Ensure the affected population has access to essential services and facilities,
including livelihoods opportunities.
•• Work with other sectors to establish an acceptable distance and safe travel
(or transport) to essential services and facilities.
•• Coordinate with service providers to prioritise and deliver essential services
and livelihoods opportunities where these do not already exist.
4.
4 Plan the use of land to provide sufficient space for all functions, accessibility
to all shelters and services, and adequate safety measures throughout the
settlement.
•• Include planning for shared resources like water and sanitation facilities,
communal cooking facilities, child-friendly spaces, gathering areas, religious
needs and food distribution points.
•• Ensure that the placement of essential services within settlements follows
standards for safety, protection and dignity.
249
5.
5 Include rainfall or floodwater drainage planning in site selection and settle-
ment development.
•• Provide appropriate drainage facilities so that all dwelling areas and
services are kept free of standing water and storm water drains are
kept clear.
•• Anticipate and manage breeding sites of disease vectors.
Key indicators
Percentage of shelters and/or settlement sites that are located in areas with no
or minimal known natural or man-made threats, risks and hazards
Percentage of shelters and/or settlement sites that have safe access to essential
services within an acceptable amount of time or distance
Percentage of those receiving settlement assistance who feel safe about the
location of their shelter or settlement
Percentage of settlement sites that offer sufficient usable surface area to carry
out private and public outdoor activities appropriate to the context
•• 45 square metres for each person in camp-type settlements, including

household plots
•• 30 square metres for each person, including household plots, where commu-
nal services can be provided outside the planned settlement area
•• Minimum ratio between covered living space and plot size is 1:2; move as
soon as possible to 1:3 or more.
Guidance notes
Planning processes and principles: Governments or local authorities often intro-
duce new policies regarding no-build zones, safe zones or buffer zones after a
crisis. Advocate for risk-informed planning and appropriate assistance options.
A “no-build zone” does not mean a “no-assistance zone”, and should not delay
shelter or settlement responses.
Understand the ownership situation of any land and property ⊕ see Shelter and
settlement standard 6: Security of tenure.
Engage the affected people in calculating and organising space to support existing
social and cultural practices. Involve women and other at-risk groups in the design
and implementation of shelter and settlement planning.
Essential services and facilities: People returning to their original homes and those
living in temporary locations or settlements require safe, secure and equitable
access to essential services and facilities, such as:
•• WASH facilities ⊕ see WASH water supply standards;

•• communal and household lighting solutions;
250
•• food storage and processing facilities (including stoves and fuel)

⊕ see Food security and nutrition assessments standard 1.1 and Food
assistance standard 6.4;
•• healthcare facilities ⊕ see Health systems standard 1.1: Health service delivery;
•• solid waste disposal ⊕ see WASH solid waste management standards;
•• schools ⊕ see INEE Handbook;
•• social facilities such as places of worship, meeting points and recreational
areas;
•• space for culturally appropriate burials and associated rituals; and
•• space for livestock accommodation (with adequate separation from residen-
tial spaces) ⊕ see LEGS Handbook.
Site planning for temporary settlements: Site layouts should be based on urban
design and town planning principles, with connecting components such as access
points, intersections and public space. These components, informed by physi-
cal, social, environmental and economic factors, form the spatial plan of the new
settlement. Settlement planning should support existing social networks, allow
opportunities for new networks to form, contribute to safety and security, and
enable self-management by the affected people.
Maintain the privacy and dignity of separate households when creating the
plot layout for temporary settlements. Each household shelter should open
onto common space or a screened area, not onto the entrance of another
shelter. Provide safe living areas for all potentially vulnerable groups, but avoid
clustering them because that can increase their vulnerability. Group together
families, extended families and groups from similar backgrounds, to retain
social bonds. Consider the needs, preferences and habits of different age, sex
and disability groups.
Surface area of planned or self-settled settlements: For planned settlements,
the minimum usable surface area is 45 square metres per person in camp-type
settlements, including household plots. This includes space for roads and foot-
paths, external cooking areas or communal cooking areas, education and recre-
ation areas, healthcare facilities, sanitation, firebreaks, administration, water
storage, site drainage, religious facilities, food distribution areas, markets,
storage and limited kitchen gardens for individual households (excluding
significant agricultural activities or livestock). Where communal services can
be provided by existing or additional facilities outside the planned settlement,
the minimum surface area should be 30 square metres per person. If the
minimum surface area cannot be provided, actively take steps to address the
consequences of higher-density occupation. Settlement planning should also
consider changes in the population.
When operating in an urban area, make use of existing services and housing stock.
Ensure adequate separation and privacy between individual households, and
reserve space for the required facilities.
251
Plot size for shelters: A ratio of shelter footprint to plot size of 1:2 or 1:3 is recom-
mended, to allow sufficient space for the most essential outdoor activities of the
households. However, a ratio closer to 1:4 or 1:5 is preferable. The ratio should
consider cultural and social norms and practical space availability.
Drainage of rainfall and floodwater: Poor drainage of rainfall or floodwater can
severely limit people’s living spaces, mobility and access to services. Generally,
site selection and infrastructure development determine the nature of large-scale
drainage systems. Avoid selecting a site that is on a floodplain; it can compromise
safety and security, particularly in congested or confined spaces. Water entering
and stagnating in people’s living, learning and working environments poses a
general threat to health, dignity and well-being.
Protect toilets and sewers from flooding, to avoid structural damage and leakage.
The main public health threat associated with poor drainage is an increased expo-
sure to diarrhoeal diseases from contact with contaminated water.
Uncontrolled water can also damage other infrastructure, dwellings and
belongings, limit livelihood opportunities and cause stress. Poor drainage also
provides conditions for vector breeding ⊕ see WASH vector control standards 4.1
and 4.2.
Access: Consider the condition of local roads and the proximity to transport hubs
for the supply of relief assistance and other goods. The supply of relief assis-
tance must avoid damaging the local road infrastructure. Consider seasonal
constraints, hazards and security risks. The site and any primary storage and
food distribution points must be accessible by heavy trucks from an all-weather
road. Other facilities must be accessible by light vehicles. Provide safe, secure
roads and pathways within settlements, and all-weather access to all individual
dwellings and communal facilities. Consider the needs of people facing mobility
or access barriers.
Fire safety: Fire risk assessments should inform site planning. Include 30-metre
firebreaks every 300 metres in built-up areas in camp settings. The space between
buildings should be at least 2 metres; ideally it should be double the building height
to prevent collapsing structures from touching adjacent buildings.
Consider local cooking and heating practices (such as type of stoves and preferred
location). Consider providing safe stoves, fire safety equipment and awareness
training to residents. Prefer fire-resistant construction materials and household
items. Inform residents (including those facing mobility or accessibility barriers)
about fire prevention, management and evacuation plans.
Reducing crime: The design of the settlement can contribute to reducing crime and
gender-based violence. Consider the location and accessibility of shelters, build-
ings and facilities, night lighting, distance to the toilet and bathing area from the
shelter, and passive surveillance through visual lines. Buildings used as collective
centres must have alternative escape routes.
252
Changing threats and risks: Undertake regular context, hazard and risk assessments
as the situation changes. This may include seasonal hazards, changes in the security
situation, unexploded ordnance on the site from previous or current conflicts,
or consequences of changing demographics.
Safety of collective centres and community infrastructure: Technical specialists
should assess the structural stability of community buildings, collective centres
and other structures in inhabited areas affected by crises. Consider actual and
potential security or health threats.
Livelihood support: Consider pre-disaster economic activities and potential
livelihoods opportunities in the post-disaster context. Identify available land for
cultivation and grazing, or access to markets and/or employment opportunities.
Shelter and settlement responses have the potential to offer local employment,
such as roles in technical assistance, supplies and the labour market. Use training
and education programmes to boost local capacity to achieve results within a set
time frame ⊕ see Shelter and settlement standard 5 and Food security and nutrition –
livelihoods standards 7.1 and 7.2.
Operation and maintenance: Create an operation and maintenance plan to
ensure the effective running of any facilities, services and utilities (such as
water, sanitation, drainage, waste management, schools). Key components of
a plan include community participation, establishing user groups, defining roles
and responsibilities, and having a cost recovery or cost sharing plan.
Decommissioning of sites and handover: Appropriate environmental rehabilitation
measures can enhance the natural regeneration of the environment in and around
temporary settlements. Sites should have a decommissioning plan, ideally devel-
oped at the design stage of the intervention ⊕ see Shelter and settlement standard 7:
Environmental sustainability.
Teaching local populations sustainable land management techniques ensures the
recovery of the site and the local environment. Use local labour in clearing and
decommissioning activities where possible.
253
3. Living space
Living space is very important for people’s well-being. It is a core human need and
right to have a place for a family to dwell, feel safe and perform a variety of essen-
tial domestic activities.

Living space
People have access to living spaces that are safe and adequate, enabling
essential household and livelihoods activities to be undertaken with dignity.
Key actions
1.
1 Ensure that each affected household has adequate living space to perform
basic domestic activities.
•• Provide living space that accommodates the diverse needs of members of
the household for sleeping, food preparation and eating, respecting local
culture and lifestyles.
•• Provide a basic roof and walls for occupants and their household assets,
offering physical security, dignity, privacy and protection from weather.
•• Provide optimal lighting conditions, ventilation and thermal comfort.
2.
2 Ensure that the space immediately surrounding the living space supports
safe access to fundamental activities.
•• Include appropriate cooking, toilets, laundry, bathing, livelihoods activities,
socialising and play areas.
3.
3 Promote the use of shelter solutions, construction techniques and materials
that are culturally and socially acceptable and environmentally sustainable.
Key indicators
Percentage of the affected population who have adequate living space in and
immediately around their shelters to carry out daily activities
•• Minimum 3.5 square metres of living space per person, excluding cooking
space, bathing area and sanitation facility
•• 4.5–5.5 square metres of living space per person in cold climates or urban
settings where internal cooking space and bathing and/or sanitation facilities
are included
•• Internal floor-to-ceiling height of at least 2 metres (2.6 metres in hot
climates) at the highest point
254
Living space
Percentage of shelters that meet agreed technical and performance standards

and are culturally acceptable
Percentage of people receiving shelter assistance that feel safe in their shelter
Guidance notes
Living space: Living space should be adequate for daily activities such as sleeping,
preparing and eating food, washing, dressing, storing food and water, and protect-
ing household possessions and other key assets. It must ensure privacy and
separation as required between sexes, different age groups and families within a
given household according to cultural and social norms ⊕ see Shelter and settlement
Consider living space for household members to gather, and for the care of infants,
children and persons who are ill or injured. Pay attention to changing use of space
during day and night, and plan the locations of windows, doors and partitions
to maximise the use of internal space and any adjacent external areas such as
kitchens or play areas.
To accommodate these activities in dignity, shelters need an enclosed space (walls,
windows, doors and roof) with adequate floor area. Overcrowding or exposure to
the elements increases the risk of disease outbreak or illness. Reduced space may
lead to protection risks, reduced security and privacy.
The minimum living space should reflect cultural and social norms, the context,
the phase of response, and guidance by national authorities or the humanitarian
response sector. Carefully consider the potential consequences of adopting the
minimum calculated space (3.5 square metres per person, 4.5 square metres in
cold climates) and agree any adaptation with partners, moving towards the
minimum as quickly as possible for all.
Where there is a need to act quickly and save lives, consider initial assistance
to either:
•• build a roof cover for the minimum living space and follow up with support
for walls, doors and windows; or
•• build a shelter with a smaller floor area and follow up to increase floor area.
In some situations, the space standard may be dictated by physical limitations.
This may be in a confined settlement, dense urban settings or in extreme climatic
conditions where shelter materials are not readily available. The minimum space
indicated is applicable in the emergency phase and in temporary or transitional
shelter solutions. When the duration of stay extends, the habitable space calcula-
tions must be revisited. In the recovery phase, acceptable local standards and exit
strategies must be taken into account.
Involve affected communities and households as much as possible in determining
the type of assistance to be provided. Consult with the people who spend more
time in the covered living space and those facing mobility or access barriers.
255
Ensure that living space is accessible for persons with disabilities and those
living with them. Persons with disabilities, particularly those with intellectual
and psychosocial disabilities, may need additional space.
Cultural practices, safety and privacy: Respect existing practices and customs and
how these affect the need for internal subdivisions (curtains, walls). For example,
design the dwelling to accommodate sleeping arrangements for extended family
members or different families within the same household.
In collective accommodation, well-planned, well-lit access routes through the
living area with partitions to screen personal and household space can provide
personal privacy and safety.
In collective accommodation, allow the option for peer groups to share space.
For example, some LGBTQI individuals prefer living with friends and peers rather
than with their own families.
Protection: Ensure there are multiple exit routes from the dwelling, and that
interior spaces open into public areas. Ensure that staff know how to refer any
protection concerns around domestic violence or abuse, violence, exploitation
or neglect of children. Women, girls and those needing assistance with personal
hygiene often require additional space ⊕ see WASH hygiene promotion standard 1.3:
Menstrual hygiene management and incontinence.
Where temporary collective accommodations are used, take specific actions
to prevent sexual exploitation and sexual violence. Work with the community
members to understand the risks and address them, and establish a strong
complaints system with immediate and verifiable actions.
Psychosocial considerations: Accommodation layout and design should include
open public household living spaces that increase options for socialising.
In warm, humid climates, design and orient shelters to maximise ventilation
and minimise entry of direct sunlight. A higher ceiling helps air circulation.
An attached covered outdoor space helps reduce direct sunlight and protect
from rain. Consider the use of adjacent shaded or covered external space for
food preparation and cooking, with separate space for other living activities.
The roof should be sloped for rainwater drainage with large overhangs, except
in locations vulnerable to high winds. The shelter construction material should
be lightweight with a low thermal capacity, such as timber. Use raised floors
to prevent water entering the covered living area ⊕ see Shelter and settlement
In hot, dry climates, heavyweight construction material (such as earth or stone) ensures
thermal comfort despite changes in night and day temperatures. Alternatively, use
a lightweight construction with adequate insulation. Pay attention to the structural
design of heavyweight construction in seismic risk areas. Provide shaded and
ventilated places where possible and appropriate. If only plastic sheeting or tents
are available, provide a double-skinned roof with ventilation between the layers to
256
Living space
reduce radiant heat gain. Position door and window openings away from the
direction of the prevailing hot wind. Internal flooring should meet the external walling
without gaps, to prevent dust and disease vectors entering.
In cold climates, a lower ceiling is preferable to minimise the internal volume that
requires heating. Shelters occupied throughout the day require heavyweight
construction with high thermal capacity. For shelters only occupied at night,
a lightweight construction with low thermal capacity and substantial insulation is
more appropriate. Minimise air flow, particularly around door and window openings,
to ensure personal comfort while also providing adequate ventilation for space
heaters or cooking stoves.
Adequate ventilation helps maintain a healthy internal environment, prevents
condensation and reduces the spread of communicable disease. It reduces the
effect of smoke from indoor household stoves, which can cause respiratory infections
and eye problems. Consider natural ventilation where possible.
Vector control: Low-lying areas, debris and vacant buildings can provide breeding
grounds for vectors that can pose public health risks. For communal settlements,
site selection and the active mitigation of vector risks are key to reducing the
impact of vector-borne diseases ⊕ see WASH vector control standard 4.2: Household
and personal actions to control vectors.
257
4. Household items
Household item assistance supports restoring and maintaining health, dignity
and safety and undertaking daily domestic activities in and around the home.
This standard addresses items for sleeping, food preparation and storage, eating
and drinking, thermal comfort, lighting and personal clothing. The WASH chapter
gives additional detail about items such as bednets, buckets, water storage and
hygiene items.

Household items
Household item assistance supports restoring and maintaining health,
dignity and safety and the undertaking of daily domestic activities in and
around the home.
Key actions
1.
1 Assess and ensure access to items that enable households to restore and
maintain essential domestic activities.
•• Consider different needs according to age, sex, disability, social and cultural
practices, and family size.
•• Prioritise access to items for domestic activities, personal clothing, personal
hygiene, and to support safety and health.
2.
2 Decide how to deliver the household item assistance effectively and
appropriately.
•• Consider what can be sourced locally through cash or voucher-based
assistance and through local, regional or international procurement for
in-kind distribution.
•• Consider environmental issues related to how items are packaged or delivered.
3.
3 Monitor the availability, quality and use of household items, and adapt as
needed.
•• Plan to replenish in cases of extended displacement.
•• Monitor the chosen markets for availability, price and quality. Adapt the way
assistance is provided as the situation evolves.
Key indicators
People have sufficient and appropriate quality clothing
•• Minimum two full sets of clothing per person, in the right size and appropriate
to culture, season and climate, and adapted to any particular needs
258
Household items
People have sufficient and appropriate quality items for safe, healthy and
private sleeping
•• Minimum one blanket and bedding (floor mat, mattress, sheeting) per
person. Additional blankets/ground insulation required in cold climates
•• Long-lasting insecticide-treated nets where needed
People have sufficient and appropriate items to prepare, eat and store food
•• Per household or group of four to five individuals: two family-sized cooking
pots with handles and lids, one basin for food preparation or serving, one
kitchen knife and two serving spoons
•• Per person: one dished plate, one set of eating utensils and one drinking
vessel
Percentage of the affected population who have access to a sufficient, safe

and affordable energy supply to maintain thermal comfort, prepare food and
provide lighting
Number of incidents of harm to people using stoves or storing or sourcing fuel

•• Establish baseline and measure progress to 0
Guidance notes
Essential household items should be available in sufficient quantity and quality for:
•• sleeping, thermal comfort and personal clothing;

•• water storage, food preparation and storage, eating and drinking;
•• lighting;
•• cooking, boiling water and heating, including fuel or energy ⊕ see Food
security and nutrition standard 5: General food security;
•• hygiene, including menstrual hygiene or incontinence items ⊕ see WASH
hygiene promotion standards 1.2 and 1.3;
•• protection from vectors; for example, mosquito nets ⊕ see WASH vector
control standard 4.2; and
•• fire and smoke safety.
Selecting appropriate household items: Household items should be provided as
part of an overall plan. When specifying the type, quantity and quality of the items,
prioritise items that are life-saving. Consider:
•• essential daily activities at the individual, household and communal levels;

•• cultural norms, appropriateness and traditions;
•• safety and ease of use (with minimal additional instruction or technical
guidance);
•• durability, rate of consumption and need for replenishment;
•• current living conditions and arrangements;
•• local availability;
259
•• specific needs according to categories of the affected population, including

women, girls, men, boys, infants, older people, persons with disabilities and
other vulnerable individuals and groups; and
•• environmental impact of the selected items ⊕ see Shelter and settlement
standard 7: Environmental sustainability.
Safety: All plastic items should be made of food-grade plastic. All metallic goods
should be stainless steel or enamelled.
Ensure safe separation between the stove and the elements of the shelter. Place
internal stoves on a non-flammable base. Install a non-flammable sleeve around
the flue where it passes through the shelter to the exterior. Locate stoves away
from entrances and to enable safe access during use. Fuel should be stored at a
safe distance from the stove itself, and any liquid fuel such as kerosene should be
kept out of the reach of children and infants.
Thermal comfort means that people are comfortably warm or cool, covered and dry.
Clothes, blankets and bedding provide personal comfort. Sleeping mats and space
heaters and coolers will create suitable living conditions. All possible measures
should be taken at individual and household level to prevent hypothermia or
heat strokes.
Affordable fuel and household energy supply: Fuel and other energy sources are
necessary for lighting, cooking, thermal comfort and communication. Collecting
or paying for fuel or energy is a recurrent cost and must be planned accordingly.
Promote energy-efficient cooking practices, including the use of fuel-efficient
stoves, firewood preparation, fire management, food preparation techniques and
shared cooking. Consult the crisis-affected people and host community about the
location and means of collecting fuel to address issues of personal safety and environ-
mental sustainability.
Artificial lighting should be provided as needed to contribute to personal safety
in and around settlements where general illumination is not available. Besides
matches and candles, consider the use of energy-efficient artificial lighting such
as light-emitting diodes (LEDs) and solar panels.
Market-based programming for household items: Market assessment for
household items should form part of a broader market system assessment.
Provision of household items should support local markets if possible. Analyse
expenditure on these items as part of overall household expenditure patterns.
Monitor them over time to adapt and adjust accordingly ⊕ see Delivering assis-
tance through markets.
Distribution: Plan efficient and equitable distribution methods in consultation with
local authorities and the affected people. Ensure that vulnerable individuals or
households are included on distribution lists and can access both the information
and the distribution itself. Distribution sites should be chosen carefully, considering
walking distance, terrain and the practicalities of transporting larger goods
260
Household items
such as shelter support items. Consider including containers for the storage and
transportation of personal and household goods.
Post-distribution monitoring: Assess the appropriateness of both the distribution
process and the household items themselves. If items are not being used or are
being sold in the market, or if there are delays in accessing the items, adapt the
process or products. Be aware that needs will change over time and programmes
should adapt to those changes.
261
5. Technical assistance
Technical assistance is an integral part of shelter and settlement responses.
It supports the self-recovery of the affected people and improves the quality and
safety of their shelter and settlement. It is essential that affected households or
communities are actively involved in choosing their accommodation, the design of
shelters, the site layout and materials, and in supervising or carrying out work to
build the shelters and other construction.

Technical assistance
People have access to appropriate technical assistance in a timely manner.
Key actions
1.
1 Understand the pre-crisis planning and building practices, available materials,
expertise and capacities.
•• Consult with affected people, local building professionals and authorities
to agree on building practices and materials and to find the required
expertise for quality assurance.
2.
2 Involve and support the affected people, local government and local profes-
sionals in the building process.
•• Comply with the applicable planning and building codes, material specifications
and quality standards, as appropriate for the intended lifespan of the shelter,
settlement and household intervention.
•• Optimise building practices and local livelihood opportunities.
3.
3 Promote safer building practices to meet current shelter needs and reduce
future risks.
•• For damaged or destroyed houses or shelters, identify the structural
risks and hazards, the reasons for any failure, or what may fail in
the future.
•• Learn from, improve and innovate local building practices and techniques
where possible; facilitate effective knowledge transfer to promote appropriate
building practices.
4.
4 Ensure that people have access to adequate technical assistance.
•• Consider the need for specialised professional expertise, how to adhere to

building codes and standards, and how to increase technical capacity among
the affected population.
262
•• Pay attention to people who have reduced capacity, ability or opportunity

to undertake construction-related activities in a safe and technically sound
manner, or negotiate occupancy of an existing safe and technically sound
property.
5.
5 Establish appropriate project management of materials, finance, labour,
technical assistance and processes for regulatory approval requirements to
ensure quality outcomes.
•• Follow appropriate tender, bidding, procurement, contract and construction
management processes and codes of conduct.
•• Encourage the use of locally available, sustainable and familiar technologies, tools
and materials and hire labour locally for maintaining and upgrading shelters.
Key indicators
Percentage of programmes where local authorities are involved in defining
construction standards and in the monitoring of construction activities
Percentage of construction activities that demonstrate active involvement of

the affected population
Percentage of shelter units that are constructed, repaired, retrofitted,

upgraded or maintained according to the agreed safe building practices for the
specific context and hazards
Percentage of households that report having received appropriate technical

assistance and guidance
Guidance notes
Participation and engagement with affected people: Participation in shelter and
construction activities should be compatible with existing local practices. Training
programmes and apprenticeship schemes can maximise opportunities for participa-
tion of all affected people (directly affected people and the host community) during
construction. Provide opportunities for women and persons with disabilities to
participate. People less able to undertake physical tasks can contribute to activities
such as site monitoring, inventory control, administrative support, childcare or
food preparation for those engaged in construction work. Be aware that affected
people may have other conflicting time constraints. Volunteer community labour
teams or contracted labour can support construction efforts of individual house-
holds, particularly those headed by women, children, older people or persons with
disabilities. Such assistance is important because those groups may be at risk of
sexual exploitation when seeking construction assistance.
Engaging young people in construction activities: Being part of a construction
project can provide young people with valuable skills, confidence, self-esteem and
connectedness to the community.
263
Ensure children under the minimum working age are not involved in shelter
construction or cash-for-work shelter programmes. Children between the minimum
working age (usually 14 or 15) and 18 years old should participate in a way that
is appropriate for their age and development. Ensure their participation is in line
with national legislation in context. Measures must be put into place to ensure
international standards and national labour law are adhered to in order to avoid
hazardous and underage child labour. Any suspected issues or questions on child
labour should be referred to child protection specialists or social services ⊕ see CPMS
Handbook.
Professional expertise: Provide advice on issues such as site and spatial planning,
local construction techniques, damage assessment, demolition and debris removal,
construction, site management, assessment of existing building stock and security
of tenure. This can ensure that shelters meet established standards. Knowledge
of material and labour markets will also be useful, as will legal and administrative
support ⊕ see Shelter and settlement standard 6: Security of tenure.
Adherence to building codes: Find out whether local or national building codes are
usually followed or enforced. If not, advocate for using and complying with them.
These codes should reflect local housing culture, climatic conditions, resources,
building and maintenance capacities, accessibility and affordability. Ensure that
shelter programmes allow households to meet or progressively attain agreed
codes and standards, especially in programmes using cash-based assistance to
meet shelter needs. Where there are no existing standards, establish Minimum
Standards in collaboration with the local authorities and relevant stakeholders
(including, where possible, the affected people) to ensure they meet safety and
performance requirements.
Increasing technical capacity: Increase community capacity by contributing to train-
ing and awareness-raising among the affected populations, local authorities, local
building professionals, skilled and unskilled labour, landlords, legal experts and local
partners.
In locations vulnerable to seasonal or cyclical crises, involve technical specialists
and local experts who have experience with appropriate local solutions or best
practices. These people can inform design and building practices and help develop
improved solutions.
Sourcing of materials: Where appropriate building materials can be provided quickly,
the affected population can construct shelters themselves. These shelter solutions
can consist of separate components or a pre-defined kit, with appropriate
construction tools. A rapid market assessment and analysis and an environmental
impact assessment should inform the selection of materials.
Sourcing materials locally may affect the local economy, workforce or the natural
environment. In some situations, adequate quality materials may not be available
locally. In those situations, use alternative materials or production processes,
or commercial shelter systems, but consider the impact of using materials that are
264
unfamiliar to the local culture. Avoid materials produced through the exploitation of
local workers and children.
Safe public buildings: Construct or repair temporary and permanent public buildings
such as schools and health centres so that they do not pose a public health risk and are
disaster-resilient. Such facilities should comply with building standards and approval
procedures. Ensure safety and access for all, including for persons facing barriers
to moving and communicating (when possible, coordinate with organisations
representing persons with disabilities). Consult with the appropriate authorities when
repairing and constructing such buildings. Establish an affordable operation and
maintenance strategy.
Procurement and construction management: Develop a construction schedule
that includes key target milestones such as start and completion dates, and the
dates and duration of the relocation of displaced people. This applies whether
the construction is managed by the owner or a contractor. The schedule should
note the expected onset of seasonal weather and include a contingency plan for
unforeseen events. Establish a construction management and monitoring system
for materials, labour and site supervision. This should address sourcing, procurement,
transportation, handling and administration throughout the process.
Hire local labour as much as possible to increase their skill set and to support
the livelihoods of the affected people. Hire specialist professionals (such as
engineers, architects, urban designers, contract managers or lawyers) to carry
out specific tasks.
Ensure that environmental concerns are addressed. Promote socially accept-
able reuse of salvaged materials where the rights to such material and its
quality can be confirmed ⊕ see Shelter and settlement standard 7: Environmental
sustainability.
Upgrading and maintenance: Initial shelter responses typically only provide a
minimum level of covered or enclosed living space. However, the initial construc-
tion methods and materials should enable households to maintain, adapt or
upgrade the shelter to meet their longer-term needs. Adaptations should be
made safely using locally available, familiar and affordable tools and materials,
where possible.
Communal tools: Establish procedures that set out how to use, maintain and safely
store communal or shared-use tools and materials.
265
6. Security of tenure
Security of tenure means that people can live in their homes without fear of forced
eviction, whether in communal settlement situations, informal settlements, host
communities or after return. It is the foundation of the right to adequate housing
and many other human rights. In the humanitarian context, an incremental – or
step-by-step – approach may be the most appropriate. This recognises that
displaced people can be supported to improve their living conditions in different
types of accommodation. It does not mean prioritising owners for assistance, nor
does it necessarily convey permanence or ownership. Shelter actors have been
developing an understanding of what is “secure enough” for the purposes of
designing shelter options that support the most vulnerable and tenure-insecure.
For more on due diligence and the concept of “secure enough” ⊕ see References:
Payne and Durand-Lasserve (2012).

Security of tenure
The affected population has security of tenure in its shelter and settlement
options.
Key actions
1.
1 Undertake due diligence in programme design and implementation.
•• Achieve as much legal certainty about tenure as possible (the “secure
enough” approach), given the context and constraints.
•• Coordinate and work with local authorities, legal professionals and intera-
gency forums.
2.
2 Understand the legal framework and the reality on the ground.
•• Map tenure systems and arrangements for the different post-crisis
shelter and settlement scenarios; identify how these affect the most
at-risk groups.
•• Work with local authorities to understand which regulations will be enforced
and which will not, and the related time frames.
•• Understand how tenure relations are managed and disputes resolved, and
how this may have changed since the onset of the crisis.
3.
3 Understand how tenure systems, arrangements and practices affect
security of tenure for at-risk groups.
•• Include security of tenure as an indicator of vulnerability.
•• Understand what documents may be required by people participating in a
programme, noting that the most vulnerable may not have, or be able to
access, these documents.
266
Security of tenure
•• Ensure that the response is not biased towards owner-occupier or freehold

arrangements.
4.
4 Implement shelter and settlement programmes to support security of
tenure.
•• Use local expertise to adapt programming to the different types of tenure,
especially for vulnerable groups.
•• Ensure that documentation, such as tenure agreements, is properly prepared
and reflects the rights of all parties.
•• Reduce the risk that the shelter programme may cause or contribute to
tensions within the community and with surrounding local communities.
5.
5 Support protection from forced eviction.
•• In case of eviction, or risk of eviction, undertake referrals to identify alternative

shelter solutions and other sectoral assistance.
•• Assist with dispute resolution.
Key indicators
Percentage of shelter recipients that have security of tenure for their shelter
and settlement option at least for the duration of a particular assistance
programme
Percentage of shelter recipients that have an appropriate agreement for

security of tenure for their shelter option
Percentage of shelter recipients with tenure challenges that have accessed,

independently or through referral, legal services and/or dispute resolution
mechanisms
•• ⊕ See Protection Principle 4.
Guidance notes
Tenure is the relationship among groups or individuals with respect to housing
and land, established through statutory law or customary, informal or religious
arrangements. Tenure systems determine who can use what resources, for how
long, and under what conditions. There are many forms of tenure arrangements,
ranging from full ownership and formal rental agreements to emergency hous-
ing and occupation of land in informal settlements. Regardless of the tenure
arrangement, all people still retain housing, land and property rights. People
living in informal settlements, who are often internally displaced, may not
possess a legal right to occupy the land but still possess the right to adequate
housing and protection against forced eviction from their home. In order to
determine whether an appropriate security of tenure is in place, information
such as tenure documentation and organisational use of due diligence methods
are required.
267
Security of tenure is an integral part of the right to adequate housing. It guarantees

legal protection against forced eviction, harassment and other threats and enables
people to live in their home in security, peace and dignity. All people, including women,
should possess a degree of security of tenure. It is important to understand how
tenure relations, including dispute resolution mechanisms, are managed and practised,
and how they may have changed since the onset of the crisis. Data to assess
security of tenure can include numbers of disputes, eviction rates and perceptions
of security of tenure.
Incremental tenure: One of the most effective ways to strengthen security of tenure
is to build on existing tenure systems that enjoy a degree of social legitimacy
⊕ see References: UN Habitat and GLTN Social Tenure Domain Model, and Payne and
Durand-Lasserve (2012).
Urban considerations: The majority of the urban displaced live in informal
settlements or in rental accommodation without formal ownership, lease and/or
use agreements. Therefore, the risk of forced eviction and related forms of
exploitation and harassment is a defining feature of their lives. Shelter and settlement
assistance options for urban areas should address complex tenure situations and
consider incremental tenure approaches for renters, informal settlers, squatters
and others.
Do no harm: In some contexts, a humanitarian shelter intervention can lead
to the eviction of vulnerable groups. In others, highlighting security of tenure
issues can increase the risk of eviction for vulnerable groups. A due diligence
approach will identify security of tenure risks facing different groups. In some
cases where the risks to security of tenure are too great, it may be best to do
nothing at all.
Common triggers for eviction: The threat of eviction comes from a complex inter-
action of factors, most of which are also triggers for exploitation and abuse.
They include:
•• inability to pay rent, often due to restrictions on livelihoods such as the right
to work;
•• absence of written lease agreements with landlords, making people
vulnerable to price increase and eviction;
•• disputes with landlords;
•• discrimination against affected people;
•• restrictions on improving the housing environment, with those in breach of
building permissions coming under constant threat of eviction;
•• users or occupants of buildable areas being unable to regularise their
situation with the civil administration;
•• housing transactions taking place within customary or religious frameworks,
and therefore not being recognised by statutory law, or vice versa;
•• for women: divorce, intimate partner violence and other forms of domestic
violence, or the death of their husband; and
268
Security of tenure
•• a lack of civil documentation for women (they may be included in their

father’s or husband’s documentation) and for other marginalised or perse-
cuted groups.
Evictions and relocation: Resettlement may be consistent with human rights

law to protect the health and safety of inhabitants exposed to natural disasters,
environmental hazards or to preserve critical environmental resources. However,
misusing regulations aimed at protecting public health and safety or the
environment to justify eviction in the absence of genuine risk, or when other
options are available, is contrary to international human rights law.
269
7. Environmental sustainability
Environmental sustainability addresses responsible programming that meets
the needs of the present without compromising the ability of future generations
to meet their own needs. Ignoring environmental issues in the short term can
compromise recovery, worsen existing problems or cause new ones ⊕ see Protection
Principle 1 and Core Humanitarian Standard Commitments 3 and 9.

Environmental sustainability
Shelter and settlement assistance minimises any negative programme
impact on the natural environment.
Key actions
1.
1 Integrate environmental impact assessment and management in all shelter
•• Assess the environmental impacts of the crisis, and environmental risks and
vulnerabilities, to minimise negative effects of the shelter and settlement
options.
•• Incorporate an environmental management plan into operations and
monitoring procedures.
2.
2 Select the most sustainable materials and techniques among the viable
options.
•• Prefer those that do not deplete local natural resources or contribute to
long-term environmental damage.
•• Salvage and reuse, recycle or re-purpose available materials, including debris.
3.
3 Manage solid waste in a safe, timely, culturally sensitive and environmentally
sustainable way in all settlements.
•• Coordinate with WASH, health, public works and other authorities, the
private sector and other stakeholders to establish or re-establish sustainable
waste management practices.
4.
4 Establish, restore and promote safe, reliable, affordable and environmentally
sustainable energy supply systems.
•• Determine whether existing energy supply systems have a negative environ-
mental impact on natural resources, pollution, health and safety.
•• Ensure any new or revised energy supply options meet user needs, and
provide training and follow-up as needed.
270
5.
5 Protect, restore and improve the ecological value of operational sites
(such as temporary settlements) during and after use.
•• Assess environmental baseline conditions and available local natural
resources for each site and identify environmental hazards, including those
due to previous commercial or industrial use.
•• Remove immediate and obvious hazards from the area and repair any
serious environmental degradation, while keeping the removal of natural
vegetation and the disruption of natural drainage at a minimum.
•• Leave the site in a state that will allow the local population to use it immedi-
ately, where possible in better condition than before.
Key indicators
Percentage of shelter and settlement activities that are preceded by an
environmental review
Number of recommendations from the environment management and moni-

toring plan that have been implemented
Percentage of shelter constructions using low carbon emission construction

materials and procurement methods
Percentage of solid waste on the site that is reused, re-purposed or recycled

•• Target > 70 per cent by volume
Percentage of temporary settlement sites that are restored to better environ-

mental conditions than before use
Guidance notes
Environmental impact assessment consists of three elements: a baseline
description of the local environment against which the assessment is occurring;
an understanding of the proposed activity and its potential threat to the environ-
ment; and an understanding of the consequences if the threat occurs.
It may be helpful to consult with appropriate environmental agencies. Key points to
consider in an environmental impact assessment include:
•• pre-crisis access to and use of local natural resources, including fuel and
construction materials, water sourcing and waste management;
•• the extent of locally available natural resources and the impact of the crisis
on these assets; and
•• social, economic and cultural issues (including gender roles) that may influ-
ence the sustainability of the response and improve its overall effectiveness
and efficiency.
271
Sourcing materials: When sourcing natural resources such as water, timber,

sand, soil and grasses, and fuel for firing bricks and roof tiles, be aware of the
environmental impact. Promote the use of multiple sources, the reuse of
salvaged materials and the production of alternative materials. Reforestation
can be a good way to produce sustainable building materials. Avoid using materials
that have been produced through exploitation of adults and children ⊕ see Delivering
assistance through markets.
Site selection: Environmental impact assessments should inform site selection.
For example, locating settlements close to existing infrastructure can reduce the
environmental impacts associated with building new infrastructure. Consider
exposure to climate-related risks ⊕ see Shelter and settlement standard 2: Location
Erosion: Retain trees and other vegetation to stabilise the soil and maximise shade
and protection from the climate. Using natural contours for services such as roads,
pathways and drainage networks minimises erosion and flooding. If necessary,
establish drainage channels, piped drainage runs under roadways or planted earth
banks to prevent soil erosion. Where the slope is more than 5 per cent, engineering
techniques must be applied to prevent excessive erosion.
Debris management and waste reuse or re-purposing: Debris management planning
immediately after the crisis promotes the salvaging of debris for reuse, re-purposing
or safe disposal.
There is potential to reuse or re-purpose solid waste found in humanitarian settings.
Reuse of materials in humanitarian settings as part of a more systematic solid waste
management strategy depends on cultural attitudes to the handling of waste and the
proximity of businesses willing to purchase the separated materials. Humanitarian
settings provide opportunities for inventive reuse of materials ⊕ see WASH excreta
management standard 3.1 and WASH solid waste management standards 5.1 and 5.3.
Energy: When working on energy consumption, consider climate, available natural
resources, indoor and outdoor pollution, health impact, safety, and user preferences.
Where possible, programmes should reduce household energy needs. Energy-
efficient design, using passive approaches to the heating or cooling of structures,
and using energy efficient household items such as solar lamps reduces household
costs and environmental impacts ⊕ see Food security and nutrition standard 5:
General food security.
Identify the risks to the public caused by damaged energy supplies, for example
damaged power lines and leaking propane or fuel oil storage tanks. Coordinate with
local government and energy vendors to restore, deliver and maintain the energy
services. Subsidies or other incentives may be an option for assuring safety and
reducing pollution or demands on natural resources.
Management of natural resources: Where there are limited natural resources to
support a substantial increase in human habitation, a resource management plan is
272
essential. If necessary, consult external experts. The resource management plan may
suggest external fuel supplies and options for livestock grazing, agricultural production
and other income streams that depend on natural resources. Large, well-managed
settlements may be more environmentally sustainable than numerous smaller,
dispersed settlements that are not as easy to manage or monitor. However, large
communal settlements may put more pressure on nearby host communities than
smaller, dispersed settlements. Shelter actors should always consider the impact of
their interventions on the host population’s needs for natural resources ⊕ see Core
Humanitarian Standard Commitment 9 and LEGS Handbook.
Urban and rural contexts: People in rural areas are generally more dependent
on the natural resources in their immediate surroundings, compared with urban
dwellers. However, urban areas absorb large quantities of natural resources
such as timber, sand and cement, bricks and other natural building materials,
coming from a much larger catchment area. Informed decisions should be taken
when using large quantities of construction materials in urban or other large-
scale shelter programmes, where environmental impacts may go far beyond the
programme implementation area.
273
Appendix 1
Shelter and settlement assessment checklist
This list of questions serves as a checklist to ensure that appropriate data is
obtained to inform the post-crisis shelter and settlement response. The list of
questions is not mandatory. Use and adapt it as appropriate.
Information on the underlying causes of the crisis, the security situation, the basic
demographics of the displaced and any host population, and the key people to
consult and contact, will need to be obtained separately.
Assessment and coordination

•• Has an agreed coordination mechanism been established by the relevant
authorities and humanitarian organisations?
•• What baseline data are available on the affected people and what are the
known hazards and shelter and settlement risks and vulnerabilities?
•• Is there a contingency plan to inform the response?
•• What initial assessment information is already available?
•• Is an interagency and/or multi-sectoral assessment planned and does this
include shelter, settlement and household items?
Demographics
•• How many people comprise an average household?
•• How many affected people are living in different types of households?
Consider groups living outside of family connections, such as groups of
unaccompanied children, households that are not average size, or others.
Disaggregate by sex, age, disability and ethnicity, linguistic or religious
affiliation as appropriate in context.
•• How many affected households lack adequate shelter, and where are these
households?
•• How many people, disaggregated by sex, age and disability, who are not
members of individual households have no or inadequate shelter, and where
are they located?
•• How many affected households that lack adequate shelter have not been
displaced and can be assisted at the site of their original homes?
•• How many affected households that lack adequate shelter are displaced and
require shelter assistance with host families or in temporary settlements?
•• How many people, disaggregated by sex and age, lack access to communal
facilities such as schools, healthcare facilities and community centres?
Risks
•• What are the immediate risks to life, health and security resulting from the
lack of adequate shelter, and how many people are at risk?
274
Appendix 1 – Shelter and settlement assessment checklist
•• What are the less immediate risks to people’s lives, health and security
resulting from the lack of adequate shelter?
•• How do tenure systems, arrangements and practices affect security of
tenure for vulnerable and marginalised populations?
•• What are the particular risks for vulnerable people, including women,
children, unaccompanied minors, and persons with disabilities or chronic
illnesses, due to the lack of adequate shelter, and why?
•• What is the impact on any host populations of the presence of displaced
people?
•• What are the potential risks for conflict or discrimination among or between
groups within the affected population, particularly for women and girls?
Resources and constraints

•• What are the material, financial and human resources of the affected
people that are available to meet some or all of their urgent shelter
needs?
•• What are the issues regarding land availability, ownership and usage that
affect people’s ability to meet urgent shelter needs, including temporary
communal settlements where required?
•• What risks may potential host populations face in accommodating displaced
people within their own dwellings or on adjacent land?
•• What are the opportunities and constraints affecting the use of existing
available and unaffected buildings or structures to accommodate displaced
people temporarily?
•• Is accessible vacant land suitable for temporary settlements, considering
topography and other environmental constraints?
•• What regulatory requirements and constraints may affect the development
of shelter solutions?
Materials, design and construction

•• What initial shelter solutions or materials have the affected people, affected
populations or other actors provided?
•• What existing materials can be salvaged from the damaged site for use in
the reconstruction of shelters?
•• What are the typical building practices of the affected people and what
materials do they use for the structural frame, roof and external wall
enclosures?
•• What alternative solutions for design or materials are potentially available
and familiar or acceptable to the affected people?
•• What design features will ensure safe and ready access to and use of shelter
solutions by all affected people?
•• How can the identified shelter solutions minimise future risks and
vulnerabilities?
•• How are shelters typically built, and by whom?
275
•• How are construction materials typically obtained, and by whom?

•• How can women, youths, persons with disabilities and older people be
trained or assisted to participate in the building of their own shelters, and
what are the constraints?
•• Where individuals or households lack the capacity or opportunity to build
their own shelters will additional assistance be required to support them?
Examples include the provision of voluntary or contracted labour or technical
assistance.
Household and livelihood activities

•• What household and livelihood support activities typically take place in or
near the shelters of the affected people, and how does the resulting space
provision and design reflect these activities?
•• What legal and environmentally sustainable livelihood support opportunities
can be provided through the sourcing of materials and the construction of
shelter and settlement solutions?
Essential services and communal facilities

•• What is the current availability of water for drinking and personal hygiene,
and what are the possibilities and constraints in meeting the anticipated
sanitation needs?
•• What is the current provision of social facilities (such as health clinics,
schools and places of worship), and what are the constraints to and opportu-
nities for accessing these facilities?
•• Where communal buildings, particularly schools, are used for sheltering
displaced people, what is the process and timeline for returning them to their
intended use?
Host population and environmental impact

•• What are the issues of concern for the host population?
•• What are the organisational and physical constraints related to accommo-
dating the displaced people within the host population or within temporary
settlements?
•• What are the environmental concerns regarding the local sourcing of
construction materials?
•• What are the environmental concerns regarding the needs of the displaced
people for fuel, sanitation, waste disposal, and grazing for animals, among
others?
Household item needs

•• What are the critical non-food items required by the affected people?
•• Can any of the required non-food items be obtained locally?
•• Is the use of cash or vouchers possible?
•• Will technical assistance be required to complement the provision of shelter
support items?
276
Appendix 1 – Shelter and settlement assessment checklist
Clothing and bedding

•• What types of clothing, blankets and bedding do women, men, children
and infants, pregnant and lactating women, persons with disabilities
and older people typically use? Are there particular social and cultural
considerations?
•• How many women and men of all ages, children and infants have inadequate
or insufficient clothing, blankets or bedding to provide protection from the
negative effects of the climate and to maintain their health, dignity and
well-being?
•• What are the potential risks to the lives, health and personal safety of the
affected people if their need for adequate clothing, blankets or bedding is
not met?
•• What vector-control measures, particularly the provision of mosquito nets,
are required to ensure the health and well-being of households?
Cooking and eating, stoves and fuel

•• What cooking and eating utensils did a typical household have access to
before the crisis?
•• How many households do not have access to sufficient cooking and eating
utensils?
•• How did affected people typically cook and heat their dwellings before the
crisis, and where did the cooking take place?
•• What fuel was typically used for cooking and heating before the crisis, and
where was this obtained?
•• How many households do not have access to a stove for cooking and heating,
and why?
•• How many households do not have access to adequate supplies of fuel for
cooking and heating?
•• What are the opportunities and constraints (in particular environmental
concerns) of sourcing adequate supplies of fuel for the crisis-affected and
neighbouring populations?
•• What is the impact on affected people, and in particular women of all ages, of
sourcing adequate supplies of fuel?
•• Are there cultural issues regarding cooking and eating to take into account?
Tools and equipment

•• Which basic tools to repair, construct or maintain a shelter are available to
the households?
•• What livelihood support activities can also utilise the basic tools for
construction, maintenance and debris removal?
•• What training or awareness-raising activities will enable the safe use
of tools?
277
Appendix 2
Description of settlement scenarios
Settlement scenarios allow for a first-level categorisation of where and how
affected people are living. An understanding of the crisis through these settlement
scenarios will help when planning assistance strategies. Gather additional details
to inform detailed planning ⊕ see Appendix 3: Additional characteristics of settlement
scenarios.
Population group Settlement Description Examples

scenario
Non-displaced people Owner- The occupant owns his or Houses, apart-
occupied her property and/or land ments, land
accommoda- (ownership may be formal or
tion or land informal) or is a part or joint
owner.
Rental Renting allows an individual
accommodation or household to use housing
or land or land for a specified period
of time at a given price, with-
out transfer of ownership,
on the basis of a written or
verbal contract with a private
or public owner.
Informally Households occupy the Empty houses,
occupied property and/or land without apartments,
accommodation the explicit permission of the vacant land
or land owner or appointed repre-
sentative of the premises.
Displaced people Rental Rental allows an individual or Houses, apart-
Dispersed arrangement household to use housing or ments, land from
land for a specified period of existing housing
time at a given price, without stock
transfer of ownership. It is
based on a written or verbal
contract with a private or
public owner. This can be
self-funded individually or
communally or subsidised by
the government or humani-
tarian community.
278
Appendix 2 – Description of settlement scenarios
Population group Settlement Description Examples

scenario
Displaced people Hosted Host populations provide Houses,
arrangement shelter for displaced popula- apartments, land
tions or individual families. already occupied
or made available
by the host
population
Spontaneous Displaced households Empty houses,
arrangement spontaneously settle in a empty apart-
location without agreement ments, vacant
with the relevant actors (such land, road side
as owner, local government,
humanitarian organisations
and/or the host population).
Communal Collective Pre-existing facility or Public buildings,
accommodation structure where multiple evacuation,
households take shelter. reception and
Infrastructure and basic transit centres,
services are provided on a abandoned build-
communal basis or access to ings, company
them is made possible. compounds,
unfinished
buildings
Planned A purpose-built settlement Formal settle-
settlement for displaced people where ments managed
the site layout is planned by government,
and managed, and where UN, NGOs or
infrastructure, facilities and civil society. Can
services are available. include transit or
reception centres
or evacuation sites
Unplanned Multiple households spon- Informal sites and
settlement taneously and collectively settlements
settle in a location, creating a
new settlement. Households
or the collective might have
rental agreements with the
landowner. This is often
without prior arrangement
with the relevant actors (such
as owner, local government
and/or the host population).
On-site basic services are
initially not planned.
279
Appendix 3
Additional characteristics of
settlement scenarios
This table sets out secondary characteristics that expand the settlement scenarios
outlined in ⊕ Appendix 2 Description of settlement scenarios. Using it to understand
the crisis in more detail should inform detailed planning processes.
Note: The choice of characteristics and their definition vary by context and should align to the relevant
guidance. Create additional characteristics as needed for a particular context.
Category Examples Notes
Types of displaced Refugees, asylum seekers, ⊕ See Humanitarian profile support

populations internally displaced persons guidance (www.humanitarianresponse.
(IDPs), refugee returnees, IDP info).
returnees, others of concern
(for example, migrants)
Indirectly affected Pre-existing populations, Host populations are often impacted
host populations by directly affected populations, for
example by sharing communal services
such as schools, or acting as host
families.
Geographic context Urban, peri-urban, rural Peri-urban: an area between consolidated
urban and rural regions.
Damage level No damage, partial damage, Categorising damage level should
fully destroyed inform whether the house or shelter
is safe to occupy.
Duration/phase Short-term, medium-term, Definitions of these terms vary and
long-term, permanent should be set at response level.
Emergency, transitional,
recovery, durable
Tenure systems Statutory, customary, Informal land or housing arrange-
religious, hybrid ments are those that include regu-
larised and unregulated squatting
Unauthorised subdivisions on legally
owned land, and various forms of
unofficial rental arrangements. In
some cases, several forms of tenure
may coexist on the same plot, with
each party entitled to certain rights.
Forms of housing Ownership, use rights, rental,
tenure collective tenure
Forms of land tenure Private, communal, collective,
open access, state/public
280
Appendix 3 – Additional characteristics of settlement scenarios
Category Examples Notes
Shelter type Tents, makeshift shelters, ⊕ See Appendix 4: Assistance options.

transitional shelter, core
shelter, houses, apartments,
rented space within a bigger
unit, garages, caravans,
containers
Site management Managed, remote or mobile Managed: with no objection from
managed, self-managed, no landowner, and endorsed by
management authorities.
Remote or mobile managed: in cases
where a team is managing a number
of sites.
Self-managed: by community leader-
ship structure or internal committees.
281
Appendix 4
Assistance options
A range of context-specific assistance options can be combined to meet the needs
of affected people. Consider the advantages and disadvantages of each and
develop the most appropriate programme.
Assistance option Description

Household items ⊕ see Shelter and settlement standard 4: Household items.
Shelter kits Construction material, tools and fixtures needed to create or improve
living space. Consider whether to supply structural materials such as poles
and pegs or if they can be supplied by the households. Consider the need
for additional instruction, promotion, education or awareness-raising.
Shelter toolkits Construction tools and hardware needed to create or improve living space
and settlement.
Tents Premanufactured portable shelters with a cover and a structure.
Return and transit Support for affected people who choose to return to their place of origin
support or relocate to a new location. Such support may include a wide range of
services such as providing transport, transport fares or vouchers, or items
such as tools, materials and seed stocks.
Repairs Repair describes restoring a building from damage or decay to a sound
working condition where it meets the required standards and specifica-
tions. If buildings have suffered minor damage, it is possible to
repair them without a more major retrofit. For displaced people it may be
necessary to repair collective centres or to upgrade pre-existing buildings
such as schools for mass shelter.
Retrofitting Retrofit of the buildings involves strengthening and/or structural system
modification of the buildings’ structure. The goal is to make a building
more resistant to future hazards by having safety features installed.
Buildings that were damaged by the crisis may need to be retrofitted in
addition to being repaired. For displaced people, it may be necessary to
retrofit houses of host families, if they are at risk from a hazard.
Host assistance People who are unable to return to their original homes often stay with
family and friends or communities with shared historical, religious or
other ties. Supporting the host to continue to shelter affected people
includes support to expand or adapt an existing host family shelter, or
financial and material support for running costs.
Rental assistance Assistance to affected households to rent accommodation and land can
include financial contributions, support to obtain a fair agreement or
advice on property standards. Rent is an ongoing expense, thus plan exit
strategies, promoting self-sufficiency or connecting livelihood activities
early ⊕ see Shelter and settlement standard 3: Living space and standard 6:
Security of tenure. (Note: Rental assistance can inject cash into the host
population or it can exhaust the market and cause inflation.)
282
Appendix 4 – Assistance options

Temporary shelters Short-term shelter solutions, which are intended to be removed once the
next stage of shelter solution is offered. Usually these are constructed
with limited costs.
Transitional Rapid shelters designed from materials and techniques that are designed
shelters to transition into more permanent structures. The shelter should be
upgradeable, reusable, resaleable or moveable from temporary sites to
permanent locations.
Core housing Housing units planned, designed and constructed to be eventually part
of a permanent house, but not completing it. Core housing allows the
future process of extension by the household through its own means and
resources. The aim is to create a safe and adequate living space of one or
two rooms together with water and sanitation facilities and the necessary
household items ⊕ see Shelter and settlement standard 3: Living space and
standard 4: Household items.
Reconstruction/ Demolishing and rebuilding structures that cannot be repaired.
rebuilding
Information Information centres offer advice and guidance to affected people.
centres Information provided through local centres may clarify rights to advice
and assistance, options and processes for return; rights to land, access
to compensation, technical advice and assistance, return, integration and
relocation; and channels to offer feedback; and ways to seek redress,
including arbitration and legal aid.
Legal and adminis- Providing legal and administrative expertise helps the affected people to
trative expertise be aware of their rights and to receive the administrative support they
need free of charge or at a reduced cost. Particular attention should be
paid to the needs of the most vulnerable groups.
Securing tenure Support in securing housing and/or land occupation rights for the affected
people guarantees legal protection against forced eviction, harassment
and other threats, and provides security, peace and dignity ⊕ see Shelter
and settlement standard 6: Security of tenure.
Infrastructure Infrastructure and settlement planning support is used to improve
and settlement the services of a community and support the planning of sustainable
planning transitional settlement and reconstruction solutions. Infrastructure and
settlement planning support may be divided into two categories: that
which is coordinated primarily by the shelter sector and those that are
primarily coordinated by other sectors.
Collective Existing buildings can be used as collective centres or evacuation centres
accommodation and to provide rapid shelter. These can be schools, community buildings,
support covered playgrounds, religious facilities or vacant properties. Such prop-
erties may require adaptation or upgrading for habitation ⊕ see Shelter
and settlement standard 3: Living space. When using school buildings to
accommodate crisis-affected people, identify and utilise alternative
structures immediately to enable schooling to continue ⊕ see Collective
Centre Guidelines and INEE Handbook.
Managing settle- ⊕ See Collective Centre Guidelines.
ments and collective
centres
283

Debris removal and Debris removal helps improve public safety and access to the affected
management of the people. Consider environmental impact as well ⊕ see Shelter and
dead settlement standards 2 and 7.
Handle and identify the dead appropriately ⊕ see Health 1.1 and WASH 6.
Rehabilitate and/ Rehabilitate or construct infrastructure such as water supply, sanitation,
or install common roads, drainage , bridges and electricity ⊕ See WASH chapter for guidance,
infrastructure and Shelter and settlement standard 2: Location and settlement planning.
Rehabilitate and/or Education: Schools, child-friendly spaces, safe play areas ⊕ see INEE
construct Handbook;
community Health service: Health centres and hospitals ⊕ see Health systems standard
facilities 1.1: Health service delivery;
Security: Police posts or community watch structures;
Communal activities: Meeting places for decision-making, recreation and
worship, fuel storage, cooking facilities and solid waste disposal; and
Economic activities: Markets, land and space for livestock, space for
livelihoods and business.
Urban/village When re-planning residential areas after a crisis, involve local authorities
planning and and urban planners, so that regulations and mutual interests of all
zoning stakeholders are respected ⊕ see Shelter and settlement standard 2:
Location and settlement planning.
Relocation Relocation is a process that involves rebuilding a family’s or a community’s
housing, assets and public infrastructure in a different location.
284
Appendix 5 – Implementation options
Appendix 5
Implementation options
The assistance delivery method influences the quality, timing, scale of delivery and
cost. Select implementation options based on an understanding of local markets,
including commodity, labour and rental markets, in support of economic recovery
⊕ see Delivering assistance through markets. Consider the impact of the selected
implementation options on the degree of participation and sense of ownership,
gender dynamics, social cohesion and livelihoods opportunities.
Implementation option Description

Technical assistance Technical assistance is an integral part of any shelter and settlement
and quality assurance response, regardless of the assistance ⊕ see Shelter and settlement
standard 5: Technical assistance.
Financial support Through financial support, households and communities can access
goods or services or meet their shelter and settlement needs.
According to the risk and complexities of the task, complement
financial support with technical assistance and capacity building.
Market-based transfers include the following options:
Conditional cash transfers: Useful when it is vital to meet specific
conditions; for example, Tranche system.
Restricted cash or vouchers: Useful for specific goods or engaging
vendors.
Unconditional, unrestricted or multipurpose.
Access to financial services such as savings groups, loans, micro-credit,
insurance and guarantees.
⊕ see Delivering assistance through markets.
In-kind material Procuring and then distributing items and materials directly to
support affected households is an option when local markets are not able to
supply the appropriate quality or quantity or in a timely manner
⊕ see Delivering assistance through markets.
Commissioned labour Commissioning or contracting labour to achieve shelter and settlement
and contracting goals through owner-driven, contractor-driven or agency-driven models
⊕ see Shelter and settlement standard 5: Technical assistance.
Capacity building Skills enhancement and training offer opportunities for stakeholders
to increase their ability to respond, individually and collectively, and
also to interact and consider together common challenges and tools
such as developing and implementing building standards and codes
⊕ see Shelter and settlement standard 5: Technical assistance.
Successful capacity building should allow experts to concentrate on
supervising activities undertaken by local stakeholders and to provide
their assistance to a higher number of persons receiving assistance.
For a table with potential assistance and implementation options connected to settle-
ment scenarios please go to www.spherestandards.org/handbook/online-resources
285
Settlement scenario
Non-displaced Displaced
Dispersed Communal
Owner Rented Informally Rental Hosted Spontaneous Collective Planned Unplanned Indirectly
occupied accommo- occupied arrange- arrange- arrangement accommo- settlement settlement affected
accommoda- dation or accommoda- ment ment dation
tion or land land tion or land
Assistance Household Household items X X X X X X X X X X

options shelter
Appendix 6
Shelter kits X X X X X X X X X X
scale
Shelter toolkits X X X X X X X X X X
Tents X X X X X X X X
Return and X X X X X X
transit support
Repairs X X X X X X X
Retrofitting X X X X X X
Host assistance X X X X
Rental X
assistance
Temporary X X X X X X
shelters
Transitional X X X X X X
shelters
Core housing X X X X
Reconstruction/ X X
rebuilding
Potential assistance and implementation
options connected to settlement scenarios
Settlement scenario
Dispersed Communal
Settle- Information X X X X X X X X X X
ment centres
scale Legal and X X X X X X X X X X
administrative
expertise
Securing tenure X X X X X X X X
Infrastructure X X X X X
and settlement
planning
Urban/village X X X X X X X X
planning and
zoning
Collective X X
accommodation
support
Managing X X X X
settlements
and collective
centres
Debris X X X X X X X X X X
removal and
management of
the deceased
Rehabilitate X X X X X X X X X X
and/or install
common
infrastructure
Appendix 6 – Potential assistance and implementation options
Settlement scenario
Dispersed Communal
Rehabilitate and/ X X X X X X X X X X
or construct
community
facilities
Urban/village X X X X X X X X X X
planning and
zoning
Relocation X X X X X X X X X
Imple- Technical assis- X X X X X X X X X
mentation tance and quality
options assurance
Financial support X X X X X X X X X
In-kind material X X X X X X X X X
support
Commissioned X X X X X X X X X
labour and
contracting
Capacity building X X X X X X X X X

International legal instruments
Article 25 Universal Declaration of Human Rights. Archive of the International Council
on Human Rights Policy, 1948. www.claiminghumanrights.org
General Comment No. 4: The Right to Adequate Housing (Art. 11.1 of the Covenant).
UN Committee on Economic, Social and Cultural Rights, 1991. www.refworld.org
General Comment 7: The right to adequate housing (Art. 11.1 of the Covenant): forced
evictions. UN Committee on Economic, Social and Cultural Rights, 1997.
www.escr-net.org
Guiding Principles on Internal Displacement. OCHA, 1998.
www.internal-displacement.org
Pinheiro, P. Principles on Housing and Property Restitution for Refugees and Displaced
Persons. OHCHR, 2005. www.unhcr.org
Refugee Convention. UNHCR, 1951. www.unhcr.org
General
Camp Closure Guidelines. Global CCCM Cluster, 2014. www.globalcccmcluster.org
Emergency Handbook, 4th Edition. UNHCR, 2015. emergency.unhcr.org
Humanitarian Civil-Military Coordination: A Guide for the Military. UNOCHA, 2014.
https://docs.unocha.org
Humanitarian inclusion standards for older people and people with disabilities. Age and
Disability Consortium, 2018. www.refworld.org
Minimum Standards for Education: Preparedness, Recovery and Response.
The Inter-Agency Network for Education in Emergencies [INEE], 2010.
www.ineesite.org
Minimum Standard for Market Analysis (MISMA). The Cash Learning Partnership (CaLP),
2017. www.cashlearning.org
Post-Disaster Settlement Planning Guidelines. IFRC, 2012. www.ifrc.org
UN-CMCoord Field Handbook. UN OCHA, 2015. https://www.unocha.org
Settlement scenarios
Humanitarian Profile Support Guidance. IASC Information Management Working
Group, 2016. www.humanitarianresponse.info
Shelter after Disaster. Shelter Centre, 2010. http://shelterprojects.org
286
Temporary communal settlement

Collective Centre Guidelines. UNHCR and IOM, 2010. https://www.globalcccmcluster.org
Cash, vouchers, market assessments/Disabilities

All Under One Roof: Disability-inclusive Shelter and Settlements in Emergencies. IFRC,
2015. www.ifrc.org
CaLP CBA quality toolbox. http://pqtoolbox.cashlearning.org
Gender and gender-based violence

Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian
Action. Inter-Agency Standing Committee (IASC), 2015. Part 3, section 11: Shelter,
Settlement and Recovery. https://gbvguidelines.org
IASC Gender Handbook for Humanitarian Action. IASC, 2017. https://reliefweb.int
Security of Tenure in Humanitarian Shelter Operations. NRC and IFRC, 2014. www.ifrc.org
Child protection
Minimum Standards for Child Protection in Humanitarian Action: Standard 24. Alliance for
Child Protection in Humanitarian Action, Global Protection Cluster, 2012. http://cpwg.net
Schools and public buildings

Guidance Notes on Safer School Construction (INEE Toolkit). INEE, 2009.
http://toolkit.ineesite.org
Urban context
Urban Informal Settlers Displaced by Disasters: Challenges to Housing Responses. IDMC,
2015. www.internal-displacement.org
Urban Shelter Guidelines. NRC, Shelter Centre, 2010. http://shelterprojects.org
Security of tenure
Land Rights and Shelter: The Due Diligence Standard. Shelter Cluster, 2013.
www.sheltercluster.org
Payne, G. Durand-Lasserve, A. Holding On: Security of Tenure – Types, Policies,
Practices and Challenges. 2012. www.ohchr.org
Rapid Tenure Assessment Guidelines for Post-Disaster Response Planning. IFRC, 2015.
www.ifrc.org
Securing Tenure in Shelter Operations: Guidance for Humanitarian Response. NRC,
2016. https://www.sheltercluster.org
The Right to Adequate Housing, Fact Sheet 25 (Rev.1). OHCHR and UN Habitat, 2014.
www.ohchr.org
The Right to Adequate Housing, Fact Sheet 21 (Rev.1). OHCHR and UN Habitat, 2015.
www.ohchr.org
Further reading
287
Further reading
Further reading
Evictions in Beirut and Mount Lebanon: Rates and Reasons. NRC, 2014. https://
www.alnap.org/help-library/evictions-in-beirut-and-mount-lebanon-rates-and-
reasons
Housing, Land and Property Training Manual. NRC, 2012. www.nrc.no/what-we-do/
speaking-up-for-rights/training-manual-on-housing-land-and-property/
Land and Conflict: A Handbook for Humanitarians. UN Habitat, GLTN and CWGER,
2012. www.humanitarianresponse.info/en/clusters/early-recovery/document/
land-and-conflict-handbook-humanitarians
Rolnik, R. Special Rapporteur on Adequate Housing (2015) Guiding Principles on Security
of Tenure for the Urban Poor. OHCHR, 2015. www.ohchr.org/EN/Issues/Housing/
Pages/StudyOnSecurityOfTenure.aspx
Security of Tenure in Urban Areas: Guidance Note for Humanitarian Practitioners. NRC,
2017. http://pubs.iied.org/pdfs/10827IIED.pdf
Social Tenure Domain Model. UN Habitat and GLTN. https://stdm.gltn.net/
Construction management
How-to Guide: Managing Post-Disaster (Re)-Construction projects. Catholic Relief
Services, 2012. https://www.humanitarianlibrary.org/resource/managing-
post-disaster-re-construction-projects-1
Environment
Building Material Selection and Use: An Environmental Guide (BMEG). WWF Environment
and Disaster Management, 2017. http://envirodm.org/post/materialguide
Environmental assessment tools and guidance for humanitarian programming. OCHA.
www.eecentre.org/library/
Environmental Needs Assessment in Post-Disaster Situations: A Practical Guide for
Implementation. UNEP, 2008. http://wedocs.unep.org/handle/20.500.11822/17458
Flash Environmental Assessment Tool. OCHA and Environmental Emergencies Centre,
2017. www.eecentre.org/feat/
FRAME Toolkit: Framework for Assessing, Monitoring and Evaluating the Environment in
Refugee-Related Operations. UNHCR and CARE, 2009. www.unhcr.org/uk/protection/
environment/4a97d1039/frame-toolkit-framework-assessing-monitoring-evaluating-
environment-refugee.html
Green Recovery and Reconstruction: Training Toolkit for Humanitarian Action (GRRT).
WWF & American Red Cross. http://envirodm.org/green-recovery
Guidelines for Rapid Environmental Impact Assessment (REA) in Disasters. Benfield
Hazard Research Centre, University College London and CARE International, 2003.
http://pdf.usaid.gov/pdf_docs/Pnads725.pdf
F1
Shelter Environmental Impact Assessment and Action Tool 2008 Revision 3.

UNHCR and Global Shelter Cluster, 2008. www.sheltercluster.org/resources/
documents/shelter-environmental-impact-assessment-and-action-tool-
2008-revision-3
Quantifying Sustainability in the Aftermath of Natural Disasters (QSAND). IFRC and BRE
Global. www.qsand.org
F2
Health
Humanitarian
Charter
Protection Core
Standard
Health
Health
Essential Healthcare
systems
Sexual and Injury and Non-

Communiable Mental Palliative
Child health reproduc- trauma communicable
diseases health care
tive health care diseases
Standard 1.1 Standard 2.1.1 Standard 2.2.1 Standard 2.3.1 Standard 2.4 Standard 2.5 standard 2.6 standard 2.7
Health Prevention Childhood Reproduct ive, Injury and Mental health Care of non- Palliative
service vaccine- maternal and trauma care communicable care
delivery preventable newborn care diseases
diseases healthcare
Standard 1.2 Standard 2.1.2 Standard 2.2.2 Standard

2.3.2
Health Surveill ance Management Sexual

workforce and outbreak of newborn violence and
detection and and childhood clinical
early response illness management
of rape
Standard 1.3 Standard 2.1.3 Standard 2.3.3
Essential Diagnosis HIV

medicines and case
and medical management
devices
standard 1.4 Standard 2.1.4
Health Outbreak
financing preparedness
and response
standard 1.5
Health
information
Appendix 1 Health assessment checklist

Appendix 2 Sample weekly surveillance reporting forms
Appendix 3 Formulas for calculating key health indicators
Appendix 4 Poisoning
290
Contents
Essential concepts in health..................................................................................................292
1. Health systems....................................................................................................................297
2. Essential healthcare...........................................................................................................311
2.1 Communicable diseases.....................................................................................311
2.2 Child health.............................................................................................................322
2.3 Sexual and reproductive health.......................................................................327
2.4 Injury and trauma care........................................................................................335
2.5 Mental health.........................................................................................................339
2.6 Non-communicable diseases...........................................................................342
2.7 Palliative care.........................................................................................................345
Appendix 1: Health assessment checklist.......................................................................349
Appendix 2: Sample weekly surveillance reporting forms.........................................351
Appendix 3: Formulas for calculating key health indicators......................................356
Appendix 4: Poisoning.............................................................................................................358
References and further reading........................................................................................................360
291
Health
Essential concepts in health

Everyone has the right to timely and appropriate healthcare
The Sphere Minimum Standards for Healthcare are a practical expression of the
right to healthcare in humanitarian contexts. The standards are grounded in
the beliefs, principles, duties and rights declared in the Humanitarian Charter.
These include the right to life with dignity, the right to protection and security, and
the right to receive humanitarian assistance on the basis of need.
Charter, including explanatory comments for humanitarian workers, ⊕ see Annex 1:
Legal foundation to Sphere.
The aim of healthcare in a crisis is to reduce excess morbidity and mortality

Humanitarian crises have a significant impact on the health and well-being of
affected populations. Access to life-saving healthcare is critical in the initial stages
of an emergency. Healthcare may also include health promotion, prevention,
treatment, rehabilitation and palliative care at any stage of the response.
The public health impact of a crisis can be both direct (injury or death from the crisis
itself) and indirect (changes in living conditions, forced displacement, lack of legal
protection or decreased access to healthcare).
Overcrowding, inadequate shelter, poor sanitation, insufficient water quantity
and quality, and reduced food security all increase the risk of malnutrition
and outbreaks of communicable diseases. Extreme stressors can also trigger
mental health conditions. Eroding social support mechanisms and self-help
systems can lead to negative coping mechanisms and reduced help-seeking
behaviour. Reduced access to healthcare and interrupted medicine supply can
disrupt ongoing treatment such as maternal healthcare and treatment for HIV,
diabetes and mental health conditions.
The primary goal of a health response during a crisis is to prevent and reduce
excess mortality and morbidity. Patterns of mortality and morbidity, and hence
healthcare needs, will vary according to the type and extent of each crisis.
The most useful indicators to monitor and evaluate the severity of a crisis are the
crude mortality rate (CMR) and the more sensitive under-five crude mortality rate
(U5CMR). A doubling or more of the baseline CMR or U5CMR indicates a significant
public health emergency and requires an immediate response ⊕ see Appendix 3:
Formulas for calculating key health indicators.
In the absence of a known baseline, the following constitutes an emergency
threshold:
•• CMR >1/10,000/day
•• U5CMR >2/10,000/day
292
Emergency thresholds must be decided at country level. Where a baseline U5CMR

already exceeds emergency thresholds, for instance, waiting for it to double would
be unethical.
Support and develop existing health systems

A health systems approach will progressively realise the right to health during
the crisis and recovery so it is important to consider how to support existing
systems. Hiring staff (national and international) will have short- and long-term
implications for national health systems. Following analysis, well-planned health
interventions can enhance existing health systems, their future recovery and
their development.
In the first phase of a crisis, prioritise targeted health and multi-sectoral rapid
assessments. Incomplete information and inaccessible areas should not impede
timely public health decision-making. Undertake more comprehensive assess-
ments as soon as possible.
Urban crises require a different approach to health responses

Urban responses must consider the population density, built environment poli-
cies, social structures and existing social services. Identifying people at risk
or without access to healthcare is challenging. The scale of need can quickly
outstrip what can be provided. People seeking refuge in towns and cities rarely
know about existing health services or how to access them, risking a further
increase in communicable diseases. Outreach will help people cope with new
urban stresses such as inadequate access to shelter, food, healthcare, jobs or
social support networks.
Rumours and misinformation spread quickly in cities. Use technology to imme-
diately supply accurate information on healthcare and services. Secondary and
tertiary healthcare providers are often more active in cities, so increase these
providers’ capacity to deliver primary healthcare. Engage them in early warning
and response systems for communicable diseases and increase their capacity to
deliver their usual specialised services.

The Minimum Standards in this chapter reflect the core content of the right to
adequate healthcare and contribute to the progressive realisation of this right
globally. This right is linked to rights to water and sanitation, food, and shelter.
Achieving the Sphere Minimum Standards in one area influences progress in other
areas. Coordinate and collaborate closely with other sectors.
Coordinate with local authorities and other responding agencies to ensure that
needs are met, efforts are not duplicated, and healthcare response quality is opti-
mised. Coordination between healthcare actors is also important to meet needs
impartially and ensure that people who are hard to reach, at risk or marginalised
also have access to care. Cross-references throughout the Handbook suggest
some potential linkages.
293
Health
Where national standards are lower than Sphere minimums, work with the govern-
ment to progressively raise them.
Priorities should be decided on the basis of sound information shared between
sectors and be reviewed as the situation evolves.
International law specifically protects the right to healthcare

Healthcare must be provided without discrimination and must be accessible,
meaning: available, acceptable, affordable and of good quality. States are obliged
to ensure this right during crises ⊕ see Annex 1: Legal foundation to Sphere.
The right to healthcare can be assured only if the:
•• population is protected;
•• professionals responsible for the health system are well trained and
committed to universal ethical principles and professional standards;
•• health system meets Minimum Standards; and
•• state is able and willing to establish and maintain safe and stable conditions
in which healthcare can be delivered.
Attacks, threats and other violent obstructions of the work of healthcare person-
nel, facilities and medical transport are a violation of international humanitarian
law. These protections are derived from the basic obligations to respect and
protect the wounded and sick.
Humanitarian organisations should carefully consider the nature of any threat
and how to address it. For example, an attack by a national army may be treated
differently from a threat from the local community ⊕ see Special considerations to
protect healthcare below.

Healthcare actors must care for the wounded and the sick humanely, delivering
impartial care without distinction, based on need. Ensuring confidentiality, data
protection and privacy is crucial to protect individuals from violence, abuse and
other problems.
Medical staff are often first responders in cases of violence against individuals,
including gender-based violence and child abuse and neglect. Train staff to identify
and refer cases to social welfare or protection actors using confidential commu-
nication and referral systems. An unaccompanied or separated child in need
of critical healthcare but without a legal guardian to consent poses a particular
protection challenge. Consult with the child and relevant local authorities if possible.
The right to life and healthcare is essential to meet the child’s best interests and
may outweigh the right to consent. Decisions must be sensitive to the context and
to cultural norms and practices. International medical evacuation and the referral
and movement of unaccompanied children requires stringent documentation as
well as the involvement of protection services and local authorities.
294
Increasingly, healthcare must be provided at sea, including international waters,

or once individuals are brought ashore. This brings specific protection challenges
and political complexities and requires careful planning, preparedness and
mitigation of protection risks.
Carefully evaluate civil–military cooperation, particularly in conflicts. Military
and armed groups can be important providers of healthcare, even for civilians.
Humanitarian agencies may – as a last resort – have to use military capabilities
such as infrastructure support to re-establish power supplies to health facilities or
provide logistics assistance such as transporting health items or medical evacu
ation. However, reliance on the military should be considered in the context
of access to healthcare and perceptions of neutrality and impartiality ⊕ see
Humanitarian Charter and Settings with domestic or international military forces in
What is Sphere?
Humanitarian Standard should be respected. Feedback mechanisms must be
put in place during healthcare responses ⊕ see Core Humanitarian Standard
Commitment 5.
Special considerations to protect healthcare

Preventing attacks on healthcare facilities, ambulances and healthcare workers
requires sustained effort at international, state and community levels. The nature
of threats will vary greatly by context and should be addressed and reported.
To protect healthcare, health actors should consider the following issues in their
work and in supporting ministries of health or other relevant parties.
During all emergencies – and especially during a conflict – health actors must
present themselves as neutral and impartial and act according to these principles,
as this may not be well understood by the parties to the conflict, the community
or the patients.
When providing critical life-saving medical services, follow humanitarian principles
and provide impartial healthcare based on need alone. To promote neutrality, care
for the wounded and the sick without distinction, ensure patient safety and
maintain confidentiality of medical information and personal data.
Acceptance from local communities, officials and parties to a conflict may help
protect healthcare. Health actors should both educate those around them and
maintain the perception of impartiality and neutrality. A healthcare facility’s
standard of care, quality of services, and location (for example, if situated near
a military camp) will also influence these perception.
Healthcare facilities typically apply a ‘no weapons’ policy, with weapons left
outside a facility or ambulance. This promotes a neutral environment, can help
avoid tensions or escalation of conflict within the facility, and can prevent the
facility from becoming a target itself.
295
Health
Take physical security measures to protect the facility and staff from hazards.
At the same time, understand how security measures can affect the general
public’s perception and acceptance of the healthcare facility.
Humanitarian organisations must consider the risks and advantages in how
they profile their services and how this affects community trust and acceptance.
Keeping a low profile (for example by not branding assets or locations) may be
appropriate in some operations, while in others it might be better to display large
logos on assets or locations.
296
Health systems
1. Health systems
A well-functioning health system can respond to all healthcare needs in a crisis
so that even during a large-scale health crisis such as an Ebola outbreak, other
healthcare activities can continue. Easily treatable conditions will still be treated,
and maternal and child health primary care programmes will continue, reducing
excess mortality and morbidity. Any actor promoting, restoring or maintaining
health contributes to the overall health system. The health system encompasses
all levels, from national, regional, district and community to household carers, the
military and the private sector.
In a crisis, health systems and the provision of healthcare are often weakened,
even before demand increases. Healthcare workers may be lost, medical supplies
interrupted or infrastructure damaged. It is important to understand the impact
of the crisis on health systems to determine priorities for humanitarian response.
Humanitarian actors rarely operate in an emergency where there is no pre-
existing health system. Where a system is weak, it will need to be strengthened
or developed (for example through referral pathways, health information collation
and analysis).
The standards in this section address five core aspects of a well-functioning
health system:
•• delivery of quality health services;

•• a trained and motivated healthcare workforce;
•• appropriate supply, management and use of medicines, diagnostics material
and technology;
•• appropriate financing of healthcare; and
•• good health information and analysis.
These aspects affect each other in many ways. For instance, insufficient health-
care workers or lack of essential medicines will affect service delivery.
Leadership and coordination are vital to ensure needs are addressed in an impartial
manner. The ministry of health (MoH) usually leads and coordinates the response
and may request support from other health actors. Sometimes the ministry lacks
capacity or willingness to assume the role in an efficient and impartial manner, so
another agency should take this responsibility. If the MoH does not have access
or would not be accepted in all areas of the country, humanitarian actors should
seek to support the accepted existing system, especially in an acute emergency.
Carefully determine how to work with non-state actors and others, and their
ability to provide or coordinate healthcare for the population.
Access to the population is important but must be considered with a clear
understanding of the humanitarian principles and implications for impartial
297
Health
and neutral assistance. Coordination should occur at and between all levels of
healthcare from national to community and with other sectors such as WASH,
nutrition and education, as well as with cross-sectoral technical working groups
such as mental health and psychosocial support, gender-based violence (GBV)
and HIV.
Health systems standard 1.1:

Health service delivery
People have access to integrated quality healthcare that is safe, effective and
patient-centred.
Key actions
1.
1 Provide sufficient and appropriate healthcare at the different levels of the
health system.
•• Prioritise health services at country level or at the closest operational level
in acute emergencies, based on type of crisis, epidemiological profile and
health system capacity.
•• Identify different types of care that should be available at different levels
(household, community, healthcare facility and hospital).
2.
2 Establish or strengthen triage mechanisms and referral systems.
•• Implement protocols for triage at healthcare facilities or field locations in
conflict situations, so that those requiring immediate attention are identified
and quickly treated or stabilised before being referred and transported
elsewhere for further care.
•• Ensure effective referrals between levels of care and services, including
protected and safe emergency transport services and between sectors such
as nutrition or child protection.
3.
3 Adapt or use standardised protocols for healthcare, case management and
rational drug use.
•• Use national standards, including essential medicines lists, and adapt to the
emergency context.
•• Use international guidelines if national guidelines are outdated or not
available.
4.
4 Provide healthcare that guarantees patients’ rights to dignity, privacy,
confidentiality, safety and informed consent.
•• Ensure safety and privacy so that everyone may access care, including
people with conditions often associated with stigma, such as HIV or sexually
transmitted infections (STIs).
298
Health systems
5.
5 Provide safe healthcare and prevent harm, adverse medical events
or abuse.
•• Implement a system to report and review adverse medical events.
•• Establish a policy to report any abuse or sexual violence.
6.
6 Use appropriate infection prevention and control (IPC) measures, including
minimum WASH standards and medical waste disposal mechanisms, in all
•• During disease outbreaks such as cholera or Ebola, seek comprehensive
guidance from specialist bodies such as the World Health Organization
(WHO) UNICEF and Médecins Sans Frontières (MSF).
7.
7 Manage or bury the dead in a safe, dignified, culturally appropriate manner,
based on good public health practice.
Key indicators
Percentage of population that can access primary healthcare within one hour’s
walk from dwellings
•• Minimum 80 per cent
Percentage of healthcare facilities that deliver prioritised health services

Number of inpatient beds (excluding maternity beds) per 10,000 people

•• Minimum 18
Percentage of population requiring a referral seen at the next level of

healthcare
Percentage of patients referred in adequate time
Guidance notes
Access to healthcare depends on availability of healthcare, including physical
reach, acceptability and affordability for all.
Availability: Healthcare can be delivered through a combination of community-
level, mobile and fixed healthcare facilities. The number, type and location
of each will vary by context. A broad guideline for planning coverage of fixed
healthcare facilities is:
•• One healthcare facility per 10,000 people; and

•• One district or rural hospital per 250,000 people.
These do not ensure adequate healthcare coverage in all settings, however.

In rural areas, a better target may be one facility for 50,000 people, combined with
299
Health
community case management programmes and mobile clinics. In urban areas,

secondary healthcare facilities may be the first point of access and therefore cover
primary care for a larger population than 10,000.
Providing surge capacity for healthcare is critical in emergencies. Avoid dupli-
cating existing services, which can waste resources and reduce trust in existing
facilities. People need to confidently return to those facilities when temporary
facilities close.
Monitor the utilisation rate of services. Low rates may indicate poor quality,
direct or indirect cost barriers, preference for other services, overestimation
of the population or other access problems. Higher rates may suggest a public
health problem or underestimation of the target population, or may indicate
access problems elsewhere. All data should be analysed by sex, age, disability,
ethnic origin and other factors that may be relevant in context. To calculate utili-
sation rate ⊕ see Appendix 3.
Acceptability: Consult with all sections of the community to identify and address
obstacles to accessing services by different parts of the community and all sides in
a conflict, especially at-risk groups. Work with women, men, children, people living
with and at high risk of HIV, persons with disabilities, and older people to under-
stand health-seeking behaviour. Engaging with people in the design of healthcare
will build patient engagement and improve timeliness of care.
Affordability: ⊕ See Health systems standard 1.4: Health financing.
Community-level care: Primary healthcare includes household and community
care. Access to primary healthcare may be through community health work-
ers (CHWs) or volunteers, peer educators, or in collaboration with village health
committees to increase patient and community engagement. Care may range
from prevention programmes to health promotion or case management and
depends on context. All programmes should establish links with the nearest
primary healthcare facility to ensure integrated care, clinical supervision and
programme monitoring. If CHWs are screening for acute malnutrition, referral to
nutrition services at healthcare facilities or other locations is needed ⊕ see Food
security and nutrition assessments standard 1.2: Nutrition assessment. Integrate care
with community programmes in other sectors such as WASH and nutrition ⊕ see
WASH hygiene promotion standard 1.1 and Food security and nutrition – management
of malnutrition standard 2.1.
Emergency referral systems with pre-determined, safe and protected transport
mechanisms should be available 24 hours a day, seven days a week. There should
be a clinical handover between referrer and receiving healthcare provider.
Patients’ rights: Design healthcare facilities and services to ensure privacy and
confidentiality, such as with separate consultation rooms. Seek informed consent
from patients or their guardians before medical or surgical procedures. Address
any special considerations that can influence informed consent and safety, such
300
Health systems
as age, gender, disability, language or ethnicity. Establish patient feedback mecha-

nisms as early as possible. Protect patient data ⊕ see Health systems standard 1.5:
Health information.
Appropriate and safe facilities: Apply rational drug-use protocols and safe
management of medicines and devices ⊕ see Health systems standard 1.3:
Essential medicines and medical devices.
Ensure that facilities are suitable, even in emergencies. Ensure private spaces for
consultations, organised patient flow, a 1-metre space between beds, ventilation,
a sterilisation room (not open air) for hospitals, sufficient energy supply to support
critical equipment, and adequate WASH structures. During disease outbreaks,
review infrastructure requirements and guidance including, for example, triage,
observation and isolation zones.
Devise measures to make healthcare facilities safe, protected and accessible
during a crisis such as flooding or conflict.
Infection prevention and control (IPC) is key in all settings to prevent disease
and antimicrobial resistance. Even in a non-crisis setting, globally 12 per cent of
patients will develop an infection while receiving healthcare, and 50 per cent
of infections after surgery are resistant to well-known antibiotics.
Core IPC components include producing and implementing guidelines (on standard
precautions, transmission-based precautions and clinical aseptic techniques),
having an IPC team in each setting, training healthcare workforce, monitoring
programmes and incorporating detection of healthcare-associated infections
and antimicrobial resistance into surveillance systems. Healthcare settings
should have appropriate staffing and workload, bed occupancy (not more than
one patient per bed), built environment and should maintain safe hygiene practice
⊕ see Health systems standard 1.2: Healthcare workforce, ⊕ see Appropriate and safe
facilities above, WASH infrastructure and equipment, ⊕ see WASH standard 6: WASH
in healthcare settings.
Standard precautions are a part of IPC measures and include:
•• Prevention of injuries from sharps: Handle needles, scalpels and other sharps
with care, for example when cleaning used instruments or disposing of
used needles. Anyone with a sharps injury should be offered post-exposure
prophylaxis (PEP) for HIV within 72 hours ⊕ see Essential healthcare – sexual
and reproductive health standard 2.3.3: HIV.
•• Use of personal protective equipment (PPE): Provide appropriate PPE based on
risk and the task to be performed. Assess the type of exposure anticipated
(for example, splash, spray, contact or touch) and the category of transmission
of disease, the durability and appropriateness of the PPE for the task (such
as fluid-resistant or fluid-proof), and the fit of the equipment. Additional PPE
will depend on the type of transmission: contact (for example, gown or gloves),
droplet (surgical masks need to be worn when within 1 metre of the patient)
301
Health
or airborne (particulate respirators). ⊕ See WASH standard 6: WASH in healthcare

settings.
•• Other measures include hand hygiene, healthcare waste management,
maintaining a clean environment, cleaning medical devices, respiratory
and cough hygiene, and understanding principles of asepsis ⊕ see WASH
standard 6: WASH in healthcare settings.
Adverse events: Globally, 10 per cent of hospital patients suffer an adverse event
(even outside a humanitarian crisis), mostly from unsafe surgical procedures,
medication errors and healthcare-associated infections. An adverse events
register should be maintained at every healthcare facility and audited to promote
learning.
Management of the dead: Use local customs and faith practices to respect-
fully manage the dead and identify and return remains to families. Whether
an epidemic, natural disaster, conflict or mass killing, management of the dead
requires coordination between health, WASH, legal, protection and forensic
sectors.
Dead bodies rarely represent an immediate health risk. Certain diseases
(for example cholera or Ebola) require special management. Recovery of the
dead may require PPE, equipment for recovery, transportation and storage, as
well as documentation. ⊕ See WASH standard 6: WASH in healthcare settings.
Healthcare systems standard 1.2:

Healthcare workforce
People have access to healthcare workers with adequate skills at all levels of
healthcare.
Key actions
1.
1 Review existing staffing levels and distribution against national classifica-
tions to determine gaps and under-served areas.
•• Track staffing levels per 1,000 people by function and place of employment.
2.
2 Train staff for their roles according to national standards or international
guidelines.
•• Recognise that staff in acute emergencies may have expanded roles and
need training and support.
•• Introduce refresher training where turnover is high.
3.
3 Support healthcare workers to operate in a safe working environment.
•• Implement and advocate for all possible measures to protect healthcare

workers in conflicts.
302
Health systems
•• Provide occupational health training and immunisations for hepatitis B and

tetanus for clinical workers.
•• Supply adequate IPC and PPE to carry out staff duties.
4.
4 Develop incentive and salary strategies that minimise pay differences and
inequitable distribution of healthcare workers between MoH and other
healthcare providers.
5.
5 Share healthcare workforce data and readiness information with MoH and
other relevant bodies locally and nationally.
•• Be aware of displacement and departure of healthcare workers during conflict.
Key indicators
Number of community health workers per 1,000 people

•• Minimum 1–2 community health workers
Percentage of births attended by skilled personnel (doctors, nurses, midwives)

•• minimum 80 per cent
Number of skilled birth attendant personnel (doctors, nurses, midwives)

per 10,000 people
•• minimum 23 per 10,000 people
All health staff performing clinical work have received training in clinical
protocols and case management
Guidance notes
Availability of healthcare workers: The healthcare workforce includes medical
doctors, nurses, midwives, clinical officers, laboratory technicians, pharmacists and
CHWs, as well as management and support staff. The number and profile of workers
should match the population and service needs. Understaffing can result in excessive
workloads and unsafe healthcare. Integrate existing healthcare workers into the
emergency response.
When recruiting and training local staff, follow national guidelines (or international
if national are unavailable). International staff recruitment should follow national
and MoH regulations (for example evidence of qualifications, especially for clinical
practice).
Consider care for people in hard-to-reach rural and urban areas, including
those close to conflict. Staff must provide care to people of all ethnicities,
languages and affiliations. Recruit and train lower-level healthcare workers
for community outreach, case management in mobile teams or health posts,
and develop strong referral mechanisms. Incentive packages may be needed to
work in difficult areas.
303
Health
Community health workers (CHWs): Community programming with CHWs (including

volunteers) increases access to hard-to-reach populations, including marginalised
or stigmatised populations. If there are geographical constraints or acceptability
issues in diverse communities, one CHW may only practically be able to serve
300 people rather than 500.
CHWs’ work will vary. They may be trained in first aid or case management or
may conduct health screening. They must be linked to the nearest healthcare
facility to ensure appropriate oversight and integrated care. Often CHWs cannot
be absorbed into the health system once the emergency subsides. In some
contexts, CHWs may usually work only in rural settings, so a different model may
be needed in urban crises.
Acceptability: Meeting people’s sociocultural expectations will increase patient
engagement. Staff should reflect the population’s diversity with a mix of different
socioeconomic, ethnic, language and sexual orientation groups, and an appropriate
gender balance.
Quality: Organisations must train and supervise staff to ensure their knowledge is up
to date and their practice is safe. Align training programmes with national guide-
lines (adapted for emergencies) or agreed international guidelines.
Include training on:
•• clinical protocols and case management;
•• standard operating procedures (such as IPC, medical waste management);
•• security and safety (adapted to the level of risk); and
•• codes of conduct (such as medical ethics, patients’ rights, humanitarian
principles, child safeguarding, protection from sexual exploitation and abuse)
⊕ see Essential healthcare – sexual and reproductive health standard 2.3.2:
Sexual violence and clinical management of rape and Protection Principles.
Regular supervision and quality monitoring will encourage good practice. One-off
training will not ensure good quality. Share records of who has been trained, in
what, by whom, when and where with the MoH.

Essential medicines and medical devices
People have access to essential medicines and medical devices that are safe,
effective and of assured quality.
Key actions
1.
1 Establish standardised essential medicine and medical device lists for
priority healthcare.
•• Review existing national essential medicines and medical device lists early in
the response and adapt to the emergency context.
304
Health systems
•• Pay special attention to controlled medicines that may require special

advocacy to ensure availability.
2.
2 Establish effective management systems to ensure availability of safe
essential medicines and medical devices.
•• Include transport, storage and cold chain for vaccines as well as for the
collection and storage of blood products.
3.
3 Accept donations of medicine and medical devices only if they follow interna-
tionally recognised guidelines.
Key indicators
Number of days essential medicines are not available
•• Maximum 4 days out of 30 days
Percentage of health facilities with essential medicines

Percentage of health facilities with functional essential medical devices

All medicines dispensed to patients are within the expiry date
Guidance notes
Managing essential medicines: Essential medicines include drugs, vaccines and
blood products. Good medicine management ensures availability but also prohibits
unsafe or expired medicines. The main management elements are selection,
forecasting, procurement, storage and distribution.
Selection should be based on the national essential medicines list. Advocate to
close any gaps such as for non-communicable diseases, reproductive health, pain
relief for palliative care and surgery, anaesthesia, mental health, controlled drugs
(see below) or others.
Forecasting should be based on consumption, morbidity data and context
analysis. National medicine supplies may be disrupted if local manufacturing
is affected, warehouses are damaged or international procurement is delayed,
among other factors.
Procurement methods should adhere to national laws, customs regulations and
quality assurance mechanisms for international procurement. Advocate for
improved mechanisms if delays occur (through the MoH, lead agency, national disas-
ter management authority or humanitarian coordinator). If systems do not exist,
procure prequalified products, within expiry date and in the language of the country
and healthcare workforce.
305
Health
Storage: Medicines should be safely stored throughout the drug supply cycle.
Requirements vary between products. Medicines should not be stored directly on
the floor. Ensure separate areas for expired items (locked), flammable products
(well ventilated, with fire protection), controlled substances (with added security)
and products requiring cold chain or temperature control.
Distribution: Establish safe, protected, predictable and documented transport
mechanisms from central stocks to healthcare facilities. Partners may use a push
(automatic supply) or pull (supply on demand) system.
Safe disposal of expired medicines: Prevent environmental contamination and
hazards to people. Comply with national regulations (adapted to emergencies) or
international guidance. Ultra-high temperature incineration is costly, and pharma-
ceutical stockpiling works only in the short term ⊕ see WASH standard 6: WASH in
Essential medical devices: Define and procure necessary devices and equipment
(including laboratory reagents, larger machines) at each level of healthcare that are
nationally or internationally compliant. Include assistive devices for persons with
disabilities. Ensure safe use of devices, including regular maintenance and spare
parts supply, preferably locally. Decommission devices safely. Distribute or replace
lost assistive devices and provide clear information on use and maintenance. Refer
to rehabilitation services for appropriate size, fitting, use and maintenance. Avoid
one-off distribution.
Prequalified kits are useful in the early stages of a crisis or in pre-positioning
for preparedness. They contain prequalified essential medicines and medical
devices and vary according to health intervention. WHO is the lead provider
for Interagency Emergency Health Kits and non-communicable disease kits, in
addition to kits to manage diarrhoea, trauma and others. The United Nations
Population Fund (UNFPA) is the lead provider of sexual and reproductive
health kits.
Controlled drugs: Medicines for pain relief, mental health and post-partum
bleeding are usually controlled. As 80 per cent of low-income countries do not
have access to adequate pain relief medicines, advocate with the MoH and
government to improve availability for controlled drugs.
Blood products: Coordinate with the national blood transfusion service, where it
exists. Only collect blood from volunteers. Test all products for HIV, hepatitis B
and C, and syphilis as a minimum, with blood grouping and compatibility testing.
Store and distribute products safely. Train clinical staff in the rational use of blood
and blood products.
306
Health systems

Health financing
People have access to free priority healthcare for the duration of the crisis.
Key actions
1.
1 Plan for user fees to be abolished or temporarily suspended where they are
charged through government systems.
2.
2 Reduce indirect costs or other financial barriers to reach and use services.
Key indicators
Percentage of healthcare facilities that do not charge user fees for priority
healthcare (including consultations, treatment, investigations and provision of
medicines)
•• Target 100 per cent
Percentage of people not making any direct payment when accessing or using
healthcare (including consultations, treatment, investigations and provision of
medicines)
•• Target 100 per cent
Guidance notes
User fees: Requiring payment for services during an emergency impedes access
and may prevent people from seeking healthcare.
Suspending user fees for government healthcare providers will necessarily cause
financial strain. Consider supporting MoH facilities or those of other responsible
providers with staff salaries and incentives, extra medicines, medical devices
and assistive devices. If user fees are temporarily suspended, ensure users get
clear information about the timing and reasons, and monitor accessibility and
service quality.
Indirect costs can be minimised by providing adequate services in communities and
using planned mechanisms for transport and referral.
Cash-based assistance: The Universal Health Coverage 2030 targets state that
people should receive healthcare without undue financial hardship. There is no
clear evidence that using cash-based assistance specifically for health responses in
humanitarian contexts has a positive impact on health outcomes, as of this edition
⊕ see What is Sphere? including Delivering assistance through markets.
307
Health
Experience suggests that using cash-based assistance for health responses

may help if:
•• the emergency has stabilised;

•• there is a predictable service to support, such as ant-enatal care or chronic
disease management;
•• there is existing positive health-seeking behaviour and high demand; and
•• other critical household needs such as food and shelter have been met.

Health information
Healthcare is guided by evidence through the collection, analysis and use of
relevant public health data.
Key actions
1.
1 Strengthen or develop a health information system that provides sufficient,
accurate and up-to-date information for effective and equitable health
response.
•• Ensure the health information system includes all stakeholders, is simple to
implement and simple to collect, analyse and interpret information to steer
response.
2.
2 Strengthen or develop disease Early Warning, Alert and Response (EWAR)
mechanisms for all hazards that require an immediate response.
•• Decide which priority diseases and events to include based on the epidemio-
logical risk profile and context of the emergency.
•• Incorporate both indicator- and event-based components.
3.
3 Agree on and use common operating data and definitions.
•• Consider denominator figures, such as population, family size and age
disaggregation.
•• Establish administrative areas and geographic codes.
4.
4 Agree standard operating procedures for all health actors when using health
information.
5.
5 Ensure mechanisms to protect data to guarantee the rights and safety of
individuals, reporting units and/or populations.
6.
6 Support the lead actor to compile, analyse, interpret and disseminate health
information to all stakeholders in a timely and regular manner, and to guide
decision-making for health programmes.
•• Include coverage and utilisation of health services, and analysis and interpre-
tation of epidemiological data.
308
Health systems
Key indicators
Percentage of complete Early Warning, Alert and Response (EWAR)/surveil-
lance reports submitted on time
Frequency of health information reports produced by the lead health actor

•• Minimum monthly
Guidance notes
Health information system: A well-functioning health information system ensures
the production, analysis, dissemination and use of reliable and timely information
on health determinants, health systems performance and health status. Data may
be qualitative or quantitative and collected from various sources such as census
surveys, vital registration, population surveys, perceived needs surveys, individual
records and healthcare facility reports (such as health management information
systems). It should be flexible enough to incorporate and reflect unexpected chal-
lenges such as outbreaks or the total collapse of the health system or services.
Information will identify problems and needs at all levels of the health system.
Collect missing information through further assessment or surveys. Consider
cross-border movement of people, and the information needed or available.
Provide regular analysis on who is doing what and where.
Health management information systems (HMIS) or routine reporting use
health information generated from healthcare facilities to assess healthcare
delivery performance. An HMIS monitors delivery of specific interventions,
treatment of conditions, resources such as tracer drug availability, human
resources and utilisation rates.
Health surveillance is the continuous and systematic collection, analysis and inter-
pretation of health data. Disease surveillance specifically monitors different
diseases and patterns of progression and is often captured in HMIS reporting.
Early Warning Alert and Response (EWAR) is part of a routine health surveillance
system. It detects and generates an alert for any public health event that needs an
immediate response, such as chemical poisoning or epidemic prone diseases ⊕ see
Essential healthcare – communicable diseases standard 2.1.2: Surveillance, outbreak
detection and early response.
Standard operating procedures: Establish common definitions and ways of
conveying information across geographical locations, levels of care and health
actors. As a minimum, agree on:
•• case definitions;
•• indicators of what to monitor;
•• reporting units (such as mobile clinics, field hospitals, health posts);
309
Health
•• reporting pathways; and

•• frequency of data submission, analysis and reporting.
Disaggregation of data: Health information data should be disaggregated
by sex, age, disability, displaced and host populations, context (such as camp/
non-camp situation) and administrative level (region, district) to guide decision-
making and detect inequity for at-risk groups.
For EWAR, disaggregate mortality and morbidity data for children under and over
age five years. The aim is to quickly generate an alert; less detailed data is acceptable.
Outbreak investigations data, contact tracing, line listing and further monitoring of
disease trends must have disaggregated data.
Data management, security and confidentiality: Take adequate precautions to
protect the safety of the individual and the data. Staff should never share patient
information with anyone not directly involved in the patient’s care without the
patient’s permission. Give consideration to persons with intellectual, mental or
sensory impairment that may affect their ability to give informed consent. Be aware
that many people living with conditions such as HIV may not have disclosed their
status to their close family members. Treat data that relates to injury caused
by torture or other human rights violations, including sexual assault, with care.
Consider passing such information to appropriate actors or institutions if the indi-
vidual gives informed consent ⊕ see Protection Principle 1 and Core Humanitarian
Threats to healthcare: Threats to healthcare workers, or any violent incidents
involving healthcare workers should be reported using agreed local and national
mechanisms ⊕ see Essential concepts in health (above) and References and further
reading (below).
310
ESSENTIAL HEALTHCARE – COMMUNICABLE DISEASES
2. Essential healthcare
Essential healthcare addresses the major causes of mortality and morbidity in
a crisis-affected population. Coordinate with the ministries of health and other
official health actors to agree on which services to prioritise, when and where.
Base priorities on context, risk assessment and available evidence.
A crisis-affected population will have new and different needs, which will continue
to evolve. People may face overcrowding, multiple displacements, malnutrition,
lack of access to water, or continuing conflict. Age, gender, disability, HIV status,
linguistic or ethnic identity can further influence needs and may be significant
barriers to accessing care. Consider the needs of those living in under-served or
hard-to-reach locations.
Agree on priority services with the MoH and other health actors, focusing on those
risks most likely to occur and cause the greatest morbidity and mortality. Health
programmes should provide appropriate, effective care, taking into account the
context, logistics and resources that will be needed. Priorities may change as
the context improves or deteriorates further. This exercise should be conducted
regularly, based on available information and as the context changes.
Once mortality rates have declined or a situation has stabilised, more comprehensive
health services may be feasible. In protracted settings this may be an essential
package of health services, defined at country level.
This section outlines the essential minimum healthcare in key areas of emer-
gency response: communicable diseases, child health, sexual and reproductive
health, injury and trauma care, mental health, non-communicable diseases and
palliative care.
2.1 Communicable diseases

A humanitarian crisis, whether caused by a natural disaster, conflict or famine,
often brings increased morbidity and mortality from communicable diseases.
People moving into crowded communal settlements or shelters means that
diseases such as diarrhoea and measles spread easily. Damage to sanitation facil-
ities or a lack of clean water means that water- and vector-borne diseases are
transmitted rapidly. Reduced population immunity results in increased suscepti-
bility to disease. A breakdown of health systems can interrupt long-term treat-
ment, such as for HIV and tuberculosis (TB) provision of routine immunisations,
and treatment of simple conditions such as respiratory infections.
Acute respiratory infections, diarrhoea, measles and malaria still account for the
largest morbidity in crisis-affected populations. Acute malnutrition worsens these
diseases, especially in children under age five years, and in older people.
311
Health
The objective in a crisis is to prevent communicable diseases from the beginning,

to manage any cases, and to ensure a rapid and appropriate response if there is
an outbreak. Interventions to address communicable diseases should include
prevention, surveillance, outbreak detection, diagnosis and case management,
and outbreak response.
Communicable diseases standard 2.1.1:

Prevention
People have access to healthcare and information to prevent communicable
diseases.
Key actions
1.
1 Determine the risk of communicable diseases in the affected population.
•• Review pre-existing health information if available and surveillance data as
well as nutritional status and access to safe water and sanitation.
•• Conduct risk assessments with the affected population, including local
leaders and health professionals.
2.
2 Work with other sectors to develop general prevention measures and
establish integrated health promotion programmes at community level.
•• Address specific fears, rumours and common beliefs that could undermine
healthy behaviour.
•• Coordinate with other sectors performing outreach, such as hygiene promoters
or community nutrition workers, to ensure harmonised messaging.
3.
3 Implement vaccination measures to prevent disease.
•• Determine the need for vaccination campaigns for specific communicable

diseases based on risk, feasibility and context.
•• Resume delivery of routine vaccination via pre-existing immunisation
programme as soon as possible.
4.
4 Implement disease-specific prevention measures as needed.
•• Provide and ensure all inpatients use long-lasting insecticide-treated nets

(LLINs) in any malaria zone.
5.
5 Implement infection prevention and control (IPC) measures at all levels of
healthcare according to risk ⊕ see Health systems standard 1.1 and WASH
support in WASH standard 6: WASH in healthcare settings.
Key indicators
Percentage of people who adopt key practices promoted in health education
activities and messages
312
Percentage of affected households who report that they have received

appropriate information on communicable disease-related risks and preven-
tive action
Percentage of affected households who can describe three measures they are
taking to prevent communicable diseases
All inpatients in healthcare settings use long-lasting insecticide nets (LLINs) in

malarial zones
Incidence of major communicable diseases is stable or not increasing against

pre-crisis level
Guidance notes
Risk assessments: Conduct risk assessments with the affected population, local
leaders and health professionals. Analyse risks posed by the context and envi-
ronment, such as in crowded communal settlements and urban areas. Actively
consider different segments of the population for disease-specific factors, low
immunity or other risks.
Inter-sectoral prevention measures: Develop general prevention measures such
as appropriate hygiene, waste disposal, safe and sufficient water and vector
management. Adequate shelter, spacing of shelters and ventilation can help reduce
transmission. Exclusive breastfeeding and access to adequate nutrition contrib-
utes directly to health status ⊕ see Core Humanitarian Standard Commitment 3, WASH
hygiene promotion standard 1.1, WASH water supply standards 2.1 and 2.2, WASH solid
waste management standards 5.1 to 5.3, Shelter and settlement standard 2 and Food
security and nutrition – infant and young child feeding standards 4.1 and 4.2.
Health promotion: Engage communities to provide information in formats and
languages that are accessible for older people, persons with disabilities, women
and children. Take the time to test and validate messages on sensitive issues.
Vaccination: The decision to implement a vaccination campaign will be based on
three factors:
•• An assessment of general risk factors such as malnutrition, high burden of

chronic disease, overcrowding, inadequate WASH conditions, and disease-
specific risks such as geography, climate, season and population immunity.
•• The feasibility of a campaign, based on an assessment of the characteris-
tics of the vaccine, including availability, efficacy, safety, whether it is single
or multiple antigens, oral or injection, and its stability. Consider operational
factors such as access to population, time constraints, transport, material
requirements, cost and the ability to gain informed consent.
•• The general context, including ethical and practical constraints such as
community opposition, inequities due to lack of resources and political or
security constraints, or known threats against vaccinators.
313
Health
⊕ See Essential healthcare – child health standard 2.2.1: Childhood vaccine-preventable

diseases and Vaccination in Acute Humanitarian Crises: A Framework for Decision Making,
WHO, 2017, which covers 23 antigens, including cholera, meningitis, measles and
rotavirus.
Prevention of malaria: Where there is high to moderate malaria transmission,
provide LLINs to severely malnourished people and households, pregnant women,
children under age five years, unaccompanied children and people living with
HIV. Then prioritise people in supplementary feeding programmes, households
with children under age five and households of pregnant women. Give pregnant
women chemoprophylaxis according to national protocols and resistance patterns.
In areas with high malnutrition and measles mortality, consider targeted seasonal
malaria chemoprophylaxis.
Aedes mosquito-transmitted diseases: Dengue fever, chikungunya, Zika virus
and yellow fever are spread by the Aedes mosquito. Prevent disease through
integrated vector management. Individuals should wear clothing to prevent
being bitten, and households should use good water and waste management
practices and repellents or LLINs for young children and infants sleeping during
the day ⊕ see WASH vector control standard 4.2: Household and personal actions
to control vectors.

Surveillance, outbreak detection and early response
Surveillance and reporting systems provide early outbreak detection and
early response.
Key actions
1.
1 Strengthen or establish a context-specific disease Early Warning Alert and
Response (EWAR) mechanism.
•• Decide priority diseases and events to be included, based on epidemio-
logical risk.
•• Train healthcare workers at all levels about priority diseases and mecha-
nisms to notify health authorities and generate an alert.
•• Disseminate weekly EWAR reports to all stakeholders to take necessary action.
2.
2 Establish outbreak investigation teams.
•• Ensure actions are triggered rapidly when an alert is generated.
•• Initiate remote investigation where teams do not have access to the affected
populations, such as in active conflict areas.
3.
3 Ensure samples can be tested by rapid diagnostic tests or laboratories to
confirm an outbreak ⊕ see Essential healthcare – communicable diseases
standard 2.1.3: Diagnosis and case management.
314
Key indicators
Percentage of alerts being reported within in 24 hours
•• 90 per cent
Percentage of reported alerts being verified within 24 hours
•• 90 per cent
Percentage of verified alerts being investigated within 24 hours

•• 90 per cent
Guidance notes
Early Warning Alert and Response (EWAR): In coordination with all stakeholders,
including MoH, partners and community, strengthen or establish an EWAR system
representative of the affected population ⊕ see Health systems standard 1.5: Health
information. The system should be able to capture rumours, unusual events and
community reports.
Surveillance and early warning: Strengthen the EWAR system with partners, and
agree on reporting units, data flow, reporting tools, data analysis tools, case
definitions and frequency of reporting.
Alert generation and reporting: Alerts are unusual health events that may
signal the early stages of an outbreak. Define alert thresholds specific to each
disease and report as quickly as possible. Use event-based immediately notifiable
reporting by healthcare workers or analyse indicator-based reports (weekly or
more frequently). Log all alerts immediately and relay them to outbreak investi-
gation teams to verify.
Alert verification: Verify the alert information within 24 hours. Verification can
be done remotely, such as by phone, and involves collecting further data and
analysing the case(s) based on symptoms, date of onset, place, sex, age, health
outcomes and differential diagnoses.
Outbreak detection: If an alert is verified, conduct a field investigation within 24 hours.
Ensure teams have sufficient skills to verify alerts, perform field investigation, detect
a suspected outbreak and take laboratory samples. The investigation will confirm an
outbreak if an epidemic threshold has been reached or determine whether the alert
reflects sporadic cases or seasonal peaks.
Review cases, take samples and conduct a risk assessment. Possible outcomes are:
•• it is not a case;
•• a case is confirmed, but it is not an outbreak; or
•• a case is confirmed and an outbreak is suspected/confirmed.
Some outbreaks can only be confirmed by laboratory analysis; however, even

suspected outbreaks may still need immediate action.
315
Health
Alert and outbreak thresholds

Alert threshold Outbreak threshold
Cholera 2 cases with acute watery diarrhoea 1 confirmed case
and severe dehydration in people age 2
or above, or dying from acute watery
diarrhoea in the same area within one
week of each other
1 death from severe acute watery
diarrhoea in a person age 5 or above
1 case of acute watery diarrhoea,
testing positive for cholera by rapid
diagnostic tests in an area
Malaria Decided at country level depending on Decided at country level
context depending on context
Measles 1 case Defined at country level
Meningitis 2 cases in one week (in a population 5 cases in a week (in a popula-
<30,000) tion of <30,000)
3 cases in a week (in a population of 10 cases per 100,000 people
30,000–100,000) in a week (in a population of
30,000–100,000)
2 confirmed cases in one week
in a camp
Viral haemorrhagic 1 case 1 case
fevers
Yellow fever 1 case 1 case
Outbreak investigation and early response: Investigate further if an outbreak is

confirmed or suspected. Determine the cause/source, who has been affected,
modes of transmission and who is at risk, in order to take appropriate control
measures.
Perform descriptive epidemiology investigations, including:
•• cases, deaths and person, time and place of onset, to develop an epidemic
curve and spot map;
•• line listings which follow each case and analyse the extent of outbreak, for
example number of hospitalisations, complications, case fatality rate; and
•• calculating attack rates based on agreed population figures.
Develop a hypothesis that explains exposure and disease. Consider pathogen,

source and route of transmission.
Evaluate the hypothesis and agree an outbreak case definition. This may be more
specific than a case definition used for surveillance. Once laboratory investiga-
tions have confirmed an outbreak from numerous sources, follow the outbreak
case definition; there may be no need to continue to collect samples.
316
Communicate and update findings promptly and regularly. Implement population-

based control measures as soon as possible.
All of these activities may occur at the same time, especially during an ongoing
outbreak ⊕ see Essential healthcare – communicable diseases standard 2.1.4: Outbreak
preparedness and response.

Diagnosis and case management
People have access to effective diagnosis and treatment for infectious
diseases that contribute most significantly to morbidity and mortality.
Key actions
1.
1 Develop clear messages that encourage people to seek care for symptoms
such as fever, cough and diarrhoea.
•• Develop written materials, radio broadcasts or mobile phone messages
using accessible formats and languages.
2.
2 Use approved standard case management protocols to provide healthcare.
•• Consider implementing community-based case management such as for
malaria, diarrhoea and pneumonia.
•• Refer severe cases to higher levels of care or isolation.
3.
3 Provide adequate laboratory and diagnostic capacity, supplies and quality
assurance.
•• Determine the use of rapid diagnostic tests or laboratory testing for
pathogens, and at which level of healthcare it should be provided (for example,
rapid diagnostic tests in the community).
4.
4 Ensure treatment is not disrupted for people receiving long-term care for
communicable diseases such as TB and HIV.
•• Introduce TB control programmes only after recognised criteria are met.
•• Coordinate with HIV programmes to ensure healthcare provision for those
with HIV–TB co-infection.
Key indicators
Percentage of health centres supporting a crisis-affected population using
standardised treatment protocols for a specified illness
•• Use monthly record review to monitor trends
Percentage of suspected cases confirmed by a diagnostic method as deter-

mined by an agreed protocol
317
Health
Guidance notes
Treatment protocols: Protocols should include a package of diagnosis, treatment
and referral. If no such package is available in a crisis, consider interna-
tional guidance. Understand local drug-resistance patterns (also considering
displacement), especially for malaria, TB and typhoid. Consider clinically high-risk
groups such as children under age two years, pregnant women, older people,
people living with HIV and acutely malnourished children, who are at higher risk
for certain communicable diseases.
Acute respiratory infections: In crises, vulnerability is increased by overcrowding,
indoor smoke and poor ventilation, and malnutrition and/or vitamin A deficiency.
Reduce case fatality rates through timely identification, oral antibiotics and
referral of severe cases.
Diarrhoea and bloody diarrhoea: Control mortality rates through increased
access to and use of oral rehydration therapy and zinc supplementation
at household, community or primary healthcare level. Treatment can be at
community oral rehydration points.
Community case management: Patients with malaria, pneumonia or diarrhoea can be
treated by trained CHWs. Ensure all programmes are linked and overseen from the
nearest healthcare facility. Ensure equitable and impartial access for all.
Laboratory testing: Establish a referral network of national, regional and interna-
tional laboratory facilities to test specimens. Ensure rapid diagnostic testing for
malaria, cholera and dengue fever, plus testing of blood haemoglobin level. Provide
appropriate transport media for samples to be tested for other pathogens (such as
Cary-Blair medium for cholera).
Train healthcare workers in diagnostic methods, quality assurance, and specimen
collection, transport and documentation. Develop a protocol for definitive testing
at reference laboratories nationally, regionally or internationally. Definitive
testing includes cultures from specimens, serological and antigen testing or
RNA testing for yellow fever, viral haemorrhagic fevers and hepatitis E. Establish
protocols on safe transport mechanisms for pathogens, especially for viral
haemorrhagic fever, plague or similar. Consider aviation regulations for transport
of specimens by air.
Tuberculosis (TB) control is complex because of increasing drug resistance.
Only establish programmes if continuous access to the population and provi-
sion of care is assured for at least 12–15 months. Multi-drug-resistant TB
(MDR TB, resistant to two core anti-TB drugs, isoniazid and rifampicin) and
extensively drug-resistant TB (EDR TB, resistant to four core anti-TB drugs)
have been identified. Both these types require longer, more expensive
and more complex treatments. In crises, it is often difficult to access the diag-
nostic and sensitivity testing necessary to ensure correct selection and use of
TB medications.
318

Outbreak preparedness and response
Outbreaks are adequately prepared for and controlled in a timely and
effective manner.
Key actions
1.
1 Develop and disseminate an integrated outbreak preparedness and response
plan in partnership with all stakeholders and sectors.
•• Focus training on key staff in high-risk areas.
•• Pre-position essential medicines, medical devices, rapid tests, PPE and kits
(such as for cholera and diarrhoeal disease) in epidemic-prone areas and
areas with limited access.
2.
2 Implement disease-specific control measures once an outbreak is
detected.
•• Determine the need for a targeted vaccination campaign.
•• Scale up IPC measures, including providing isolation areas for cholera,
hepatitis E or other outbreaks.
3.
3 Create and coordinate outbreak-specific logistic and response capacity.
•• Ensure transport and storage capacity for medicines and supplies, including
cold chain for vaccines.
•• Add healthcare facility capacity, such as cholera or meningitis tents.
•• Ensure access and transport to laboratories at local, national and interna-
tional levels to test samples.
4.
4 Coordinate with other sectors as needed, including child protection.
Key indicators
Percentage of health staff in high-risk areas trained on outbreak response plan
and protocols
Case fatality rate is reduced to an acceptable level
•• Cholera <1 per cent

•• Meningitis <15 per cent
•• Hepatitis E <4 per cent in general population, 10–50 per cent in pregnant
women in third trimester
•• Diphtheria (respiratory) <5–10 per cent
•• Pertussis <4 per cent in children aged one year, <1 per cent in those aged one
to four years
•• Dengue <1 per cent
319
Health
Guidance notes
Outbreak preparedness and response plan: Develop this with health partners,
MoH, community members and leaders. WASH, nutrition, shelter and education
partners, the host government, prisons and military (if relevant) should also be
involved. Ensure that other critical health services are not compromised when
responding to the outbreak.
The plan should define:
•• outbreak response coordination mechanism at national, subnational and

community level;
•• mechanisms for community mobilisation and risk communication;
•• strengthening EWAR: disease surveillance, outbreak detection, outbreak
(epidemiological) investigation;
•• case management;
•• control measures specific to disease and context;
•• cross-sectoral measures;
•• protocols on safe transport and referral pathways of samples for laboratory
investigation;
•• contingency plans for scaling up services at different levels of care, including
establishing isolation areas in treatment centres;
•• outbreak control team capacities and surge healthcare worker require-
ments; and
•• availability of essential medicines, vaccines, medical devices, laboratory
supplies and PPE for healthcare workers, including international procure-
ment (for example, global stockpile of vaccines).
Outbreak control relies on adequate risk communication and dedicated outbreak

control teams. Contain the outbreak comprehensively so it does not spread to
new areas and to reduce the number of new cases where an outbreak is occurring.
This will require active case finding and prompt diagnosis and case management.
Provide isolation areas as needed (for example, for cholera or hepatitis E). Improve
vector control to reduce exposure to infection, use LLINs and improved hygiene
behaviour.
Vaccination campaigns
Meningitis: Serogroups A, C, W and Y can cause outbreaks in crises. Vaccines for
A and C are available for use in epidemics. Routine vaccination in crises is not
recommended and not possible for serogroups C and W. Target vaccination at
specific age groups based on known attack rates, or at those aged six months to
30 years. Given the need for lumbar puncture for a definitive diagnosis, establish
a clear case definition.
Viral haemorrhagic fever: The management and diagnosis of viral haemorrhagic fevers,
such as Ebola or Lassa fever, are based on stringent national and international
320
guidelines. This includes protocols on new vaccines and innovative treatment meth-
ods. Effective community engagement during these outbreaks is vital.
Yellow fever: Mass vaccination is recommended once a single case is confirmed in
a settlement for displaced and host populations. Combine this with Aedes vector
control measures and strict isolation of cases.
Polio: Polio is included in the WHO Expanded Programme on Immunization (EPI),
and vaccination should be restarted following the initial stages of an emergency.
Initiate mass vaccination if a case of paralytic polio is detected.
Cholera: Clear treatment and outbreak protocols should be available and coordi-
nated across sectors. Use cholera vaccines according to the WHO framework and
complement existing strategies for cholera control.
Hepatitis A and E: These present a significant risk, particularly in refugee camps.
Prevent and control outbreaks using improved sanitation and hygiene and access
to safe water.
Measles: ⊕ See Essential healthcare – child health standard 2.2.1: Childhood vaccine-
preventable diseases.
Pertussis or diphtheria: Pertussis outbreaks are common when people are
displaced. Due to concerns about risks among older recipients of the whole-cell
diphtheria, pertussis and tetanus (DPT) vaccine, be careful about a pertussis
outbreak-related vaccination campaign. Use an outbreak to address routine
immunisation gaps. Case management includes antibiotic treatment of cases and
early prophylactic treatment of contacts in households where there is an infant
or a pregnant woman. Diphtheria outbreaks are less common but still a threat
in crowded settings with low diphtheria immunity. In camps, mass diphtheria
vaccination campaigns with three separate doses of vaccine are not unknown.
Case management includes the administration of both antitoxin and antibiotic.
Case fatality rates: The acceptable case fatality rate CFR for specific diseases
varies with context and existing immunity. Aim to reduce case fatality rates
as much as possible. High case fatality rates may indicate a lack of access to
appropriate healthcare, late presentation and case management, significant
co-morbidities in the population, or poor-quality healthcare. Monitor the case
fatality rate frequently and take immediate corrective steps if higher than
expected.
Care of children: During outbreaks, consider children to be a specific group
when designing and implementing programmes. Coordinate and refer between the
health and child protection sectors. Address the risks of separating children from
their parents. The risks may be caused by morbidity and mortality of the parents or
by programme design. Focus on preventing family separation and ensure parental
or child consent for treatment. Take measures to keep education facilities open,
being mindful of necessary control measures and health education.
321
Health
2.2 Essential healthcare – child health

During crises, children are even more vulnerable to infections, diseases and other
risks to their health and lives. Not only have living conditions deteriorated, but
immunisation programmes are also interrupted. The risks are even higher for
unaccompanied and separated children.
A concerted child-focused response is required. Initially this will focus on life-
saving care, but ultimately interventions must alleviate suffering and promote
growth and development. Programmes should address the major causes of
morbidity and mortality. Globally these risks are acute respiratory infections,
diarrhoea, measles, malaria, malnutrition and neonatal causes of morbidity and
mortality.
Child health standard 2.2.1:

Childhood vaccine-preventable diseases
Children aged six months to 15 years have immunity against disease and
access to routine Expanded Programme on Immunization (EPI) services
during crises.
Key actions
1.
1 Determine whether there is a need for vaccinations, and the appropriate
approach for the emergency.
•• Base this on an assessment of risk (for example population, season),
feasability of a campaign (including need for mutliple doses, availibility),
and context (such as security, competing needs). This should be an ongoing
process as a crisis evolves ⊕ see Essential healthcare – communicable diseases
standard 2.1.1: Prevention.
2.
2 Conduct a mass measles vaccination campaign for children aged six months
to 15 years, regardless of measles vaccination history, when estimated
measles coverage is less than 90 per cent or unknown.
•• Include vitamin A for children age 6–59 months.
•• Ensure that all infants vaccinated between six and nine months receive
another dose of measles vaccine at nine months.
3.
3 Re-establish the EPI defined on p.401 and 402 EPI as soon as possible.
•• Aim for primary healthcare facilities or systems of mobile teams/outreach to

offer the national immunisation schedule for vaccine-preventable diseases at
least 20 days per month.
4.
4 Screen children attending healthcare facilities or mobile clinics for vaccination
status and administer any needed vaccinations.
322
ESSENTIAL HEALTHCARE – child health
Key indicators
Percentage of children aged six months to 15 years who have received measles
vaccination, on completion of a measles vaccination campaign
•• >95 per cent
Percentage of children aged six to 59 months who have received an appropriate

dose of vitamin A, on completion of measles vaccination campaign
•• >95 per cent
Percentage of children aged 12 months who have had three doses of DPT
•• >90 per cent
Percentage of primary healthcare facilities that offer basic EPI services at least
20 days/month
Guidance notes
Vaccination: Vaccines are vital in preventing excess deaths in acute crises. National
guidance may not cover emergencies or people who have crossed borders, so work
without delay to determine needed vaccines and create an implementation plan
that includes procurement processes. ⊕ See Essential healthcare – communicable
diseases standard 2.1.1 for guidance on risk assessment and vaccination decisions
and Health systems standard 1.3: Essential medicines and medical devices on the
procurement and storage of vaccines.
Measles vaccination: Measles immunisation is a priority health intervention
in crises.
•• Coverage: Review coverage data for displaced and host populations to

assess if routine measles immunisation coverage or measles campaign
coverage has been higher than 90 per cent for the preceding three years.
Carry out a measles campaign if vaccination coverage is less than 90 per
cent, unknown or in doubt. Administer vitamin A supplementation at the
same time. Ensure that at least 95 per cent of newcomers to a settlement
aged between six months and 15 years are vaccinated.
•• Age ranges: Some older children may have missed routine vaccination,
measles campaigns and the measles disease itself. These children
remain at risk of measles infection and can infect infants and young
children, who are at higher risk of dying from the disease. Therefore,
vaccinate up to the age of 15 years. If this is not possible, prioritise
children aged 6–59 months.
•• Repeat vaccinations: All children aged nine months to 15 years should
receive two doses of measles vaccine as part of standard national
immunisation programmes. Children between six and nine months
who have received the measles vaccine (for example, in an emergency
323
Health
campaign) should receive a further two doses at the recommended ages

according to the national schedule (usually nine months and 15 months in
high-risk areas).
Polio: Consider polio campaigns where polio outbreaks or threats to eradication

programmes exist, as determined in Vaccination in Acute Humanitarian Crises:
A Framework for Decision Making ⊕ see Essential healthcare – communicable
diseases standard 2.1.1: Prevention.
National EPI programme: Re-establish EPI promptly to protect children against
measles, diphtheria and pertussis and reduce the risk of respiratory infections.
National EPI programmes may need supplemental vaccines ⊕ see Essential
healthcare – communicable diseases standard 2.1.4: Outbreak preparedness and
response.
Vaccine safety: Ensure the safety of vaccines at all times. Follow the manu-
facturer’s instructions for storage and refrigeration ⊕ see Health systems
standard 1.3: Essential medicines and medical devices.
Informed consent: Obtain informed consent from parents or guardians to
administer vaccine. This includes an understanding of risks and potential
side effects.
Child health standard 2.2.2:

Management of newborn and childhood illness
Children have access to priority healthcare that addresses the major causes
of newborn and childhood morbidity and mortality.
Key actions
1.
1 Provide appropriate healthcare at different levels (facility, mobile clinics or
community programmes).
•• Use ‘Newborn Health in Humanitarian Settings’ guidelines for essential
newborn care ⊕ see References.
•• Consider adopting integrated community case management (iCCM) and
Integrated Management of Childhood Illness (IMCI).
2.
2 Establish a standardised system of assessment and triage at all facilities
that provide care for sick newborns or children.
•• Ensure that children with danger signs (unable to drink or breastfeed, vomits
everything, convulsions, and lethargic or unconscious) receives immediate
treatment.
•• Include assessment of trauma and chemical poisoning in contexts where
there is increased risk.
324
ESSENTIAL HEALTHCARE – child health
3.
3 Make essential medicines available in the appropriate dosages and formula-
tions for treating common childhood illnesses at all levels of care.
4.
4 Screen children for their growth and nutritional status.
•• Refer all malnourished children to nutritional services.

•• Provide facility-based treatment for children suffering from severe acute
malnutrition with complications.
5.
5 Establish an appropriate case management protocol for treating childhood
and vaccine-preventable diseases, such as diphtheria and pertussis, in
situations where the risk of outbreak is high.
•• Use existing protocols where possible.
6.
6 Design health education messages to encourage families to engage in
healthy behaviour and disease preventive practices.
•• Promote actions such as exclusive breastfeeding, infant feeding, handwashing,
keeping infants warm and encourage early childhood development.
7.
7 Design health education messages to encourage people to seek early
care for any illness such as fever, cough or diarrhoea among children and
newborns.
•• Take steps to reach children who do not have an adult or parent caring
for them.
8.
8 Identify children with a disability or developmental delay.
•• Provide advice on and referrals to care or rehabilitation services.
Key indicators
Under-five crude mortality rates
•• Fewer than 2 deaths per 10,000 per day ⊕ see Appendix 3 for calculations
Effective anti-malarial treatment provided in a timely manner to all children
under age five years presenting with malaria
•• Within 24 hours of the onset of symptoms
•• Exception for children under age five years experiencing severe acute
malnutrition
Oral rehydration salts (ORS) and zinc supplementation provided in a timely

manner to all children under age five years presenting with diarrhoea
Appropriate care provided in a timely manner to all children under age five
years presenting with pneumonia
325
Health
Guidance notes
Essential newborn care: Provide all newborns with skilled care at birth, preferably
in a healthcare facility and according to the ⊕ see ‘Integrated Management of
Pregnancy and Childbirth’ (IMPAC) and ‘Newborn Health in Humanitarian Settings’
guidelines. Whether the birth takes place with or without skilled care, essential
newborn care consists of:
•• thermal care (delay bathing, and keep the baby dry and warm with skin-to-
skin contact);
•• infection prevention (promote clean birth practices, handwashing, clean cord,
and skin and eye care);
•• feeding support (immediate and exclusive breastfeeding, not discarding
colostrum);
•• monitoring (assess for danger signs of infections or conditions that may need
referral); and
•• post-natal care (provide it at or close to home in the first week of life, with
the first 24 hours being the most critical for a post-natal care visit; aim for
three home visits in the first week of life).
Integrated management of childhood illness (IMCI) focuses on the care of

children under age five years at a primary healthcare level. After establishing IMCI,
incorporate clinical guidelines into standard protocols and train health profession-
als properly.
Integrated community case management (iCCM) is an approach to provide
timely and effective treatment of malaria, pneumonia and diarrhoea to people
with limited access to healthcare facilities, especially to children under age
five years.
Management of diarrhoea: Treat children with diarrhoea with low osmolality
oral rehydration salts (ORS) and zinc supplementations. Zinc shortens the
duration of diarrhoea, and ORS prevents dehydration. Encourage caregivers
to continue or increase breastfeeding during the episode, and to increase all
feeding after.
Management of pneumonia: If children have a cough, assess for fast or difficult
breathing and chest indrawing. If present, treat with an appropriate oral antibiotic.
Refer those with danger signs or severe pneumonia for priority care.
Fast breathing rates are age-specific:
Birth – 2 months: >60/min 12 months: >50/min
1–5 years: >40/min 5 years: >20/min
326
ESSENTIAL HEALTHCARE – Sexual and reproductive health
HIV: Where HIV prevalence is greater than 1 per cent, test all children with severe
acute malnutrition. Mothers and caregivers of HIV-exposed infants require
adapted support and advice ⊕ see Food security and nutrition standards.
Feeding separated children: Arrange supervised feeding for separated or unacco
mpanied children.
Child protection concerns: Use routine health services to identify child neglect,
abuse and exploitation. Refer cases to child protection services. Integrate iden-
tification and gender-sensitive case management procedures into routine health
services for mothers and infants, children and adolescents.
Nutrition referrals: ⊕ See Food security and nutrition standard 3: Micronutrient defi-
ciencies, and Management of malnutrition standard 2.2: Severe acute malnutrition.
Household air pollution: Consider providing alternative cooking stoves to reduce
smoke and fumes and the respiratory illness they cause ⊕ see Shelter and settle-
ment standard 3: Living space and standard 4: Household items.
Poisoning: ⊕ See Appendix 4.
2.3 Sexual and reproductive health

From the onset of a crisis, critical life-saving sexual and reproductive care must be
available. Establish comprehensive services as soon as feasible.
These critical services are part of an integrated health response and aided by
the use of reproductive health kits ⊕ see Health systems standard 1.3: Essential
Comprehensive sexual and reproductive healthcare involves upgrading existing
services, adding missing services and enhancing quality. Understanding the health
systems architecture will help determine how to support this ⊕ see Health systems
standards 1.1 to 1.5.
All individuals, including those in humanitarian settings, have the right to sexual
and reproductive health. Sexual and reproductive healthcare must respect the
cultural backgrounds and religious beliefs of the community while meeting univer-
sally recognised international human rights standards. Be sensitive to the needs
of adolescents, older people, persons with disabilities and at-risk populations,
regardless of sexual orientation or gender identity.
Emergencies elevate risks of sexual violence, including exploitation and abuse.
All actors should work together to prevent and respond, in close coordination with
the protection sector. Compile information safely and ethically. Share data only
according to agreed protocols ⊕ see Protection Principles and Health systems
standard 1.5: Health information.
327
Health
Sexual and reproductive health standard 2.3.1:

Reproductive, maternal and newborn healthcare
People have access to healthcare and family planning that prevents
excessive maternal and newborn morbidity and mortality.
Key actions
1.
1 Ensure that clean and safe delivery, essential newborn care, and emergency
obstetric and newborn care services are available at all times.
•• Establish a referral system with communication and transportation from the
community to the healthcare facility or hospital that functions at all times.
2.
2 Provide all visibly pregnant women with clean delivery packages when
access to skilled health providers and healthcare facilities cannot be
guaranteed.
3.
3 Consult the community to understand local preferences, practices and
attitudes towards contraception.
•• Involve men, and women, and adolescent boys and girls in separate and
private discussions.
4.
4 Make a range of long-acting reversible and short-acting contraceptive
methods available at healthcare facilities based on demand, in a private and
confidential setting.
•• Provide counselling that emphasises informed choice and effectiveness.
Key indicators
Skilled care is available for emergency obstetrics and newborn care at all times
•• Basic emergency obstetric and newborn care: minimum five facilities per
500,000 people
•• Comprehensive emergency obstetric and newborn care: minimum one
facility per 500,000 people
Percentage of births attended by skilled personnel

•• Minimum target: 80 per cent
Referral system for obstetric and newborn emergencies available

•• Available 24 hours/day and 7 days/week
Percentage of deliveries in health facilities by caesarean section

•• Target: 5–15 per cent
All primary health centres report availability of at least four methods of contra-
ception between three and six months after the onset of the crisis.
328
Guidance notes
Emergency obstetric and newborn care: About 4 per cent of any population will be
pregnant women, and about 15 per cent of those will experience an unpredictable
obstetric complication during pregnancy or at the time of delivery that will require
emergency obstetric care. About 5–15 per cent of deliveries will require surgery such
as caesarean section. Globally 9–15 per cent of newborns will require life-saving
emergency care. About 5–10 per cent of newborns do not breathe spontaneously
at birth and require stimulation, and half of those require resuscitation. The major
reasons for failure to breathe include pre-term birth and acute intrapartum events
resulting in severe asphyxia ⊕ see Essential healthcare – child health standard 2.2.2:
Management of newborn and childhood illness.
Basic emergency obstetrics and newborn care includes parenteral antibiotics,
uterotonic drugs (parenteral oxytocin, misoprostol), parenteral anticonvul-
sant drugs (magnesium sulphate), removal of retained products of conception
using appropriate devices, manual removal of placenta, assisted vaginal delivery
(vacuum extraction), and maternal and newborn resuscitation.
Comprehensive emergency obstetric and newborn care includes all of the
above as well as surgery under general anaesthesia (caesarean section, lapa-
rotomy), and rational and safe blood transfusion with standard precaution
measures. Post-abortion care is a life-saving intervention that is part of emer-
gency obstetric and newborn care and aims to reduce death and suffering from
the complications of miscarriage (spontaneous abortion) and unsafe abortions.
Treatment includes managing bleeding (possibly through surgical intervention)
and sepsis, and providing tetanus prophylaxis.
It is essential that both basic and comprehensive emergency obstetric and
newborn care services are available at all times.
The referral system should ensure that women or newborns have the means to
travel to and from a primary healthcare facility with basic emergency obstetric
and newborn care and to a hospital with comprehensive emergency obstetric and
newborn care.
Family planning: Engage with various groups in the community to understand
preferences and cultural attitudes. Ensure the community is aware of where
and how to access contraception. Share information in multiple formats and
languages to ensure accessibility. Engage community leaders to disseminate
the information.
Trained providers who understand the client’s preferences, culture and context
should give contraceptive counselling. Counselling should emphasise confi-
dentiality and privacy, voluntary and informed choice and consent, method
effectiveness for medical and non-medical methods, possible side effects,
management and follow-up, and guidance on removal if needed.
329
Health
A range of contraceptive types should be available immediately to meet antici

pated demand. Providers should be trained to remove long-active reversible
contraceptives.
Other services: Initiate other maternal and newborn care as soon as possible,
including ante-natal and post-natal care.
Coordination with other sectors: Coordinate with the nutrition sector to ensure
that pregnant and breastfeeding women are referred to nutrition services as
appropriate, such as for targeted supplementary feeding ⊕ see Food security and
nutrition – management of malnutrition standards 2.1 and 2.2.

Sexual violence and clinical management of rape
People have access to healthcare that is safe and responds to the needs of
survivors of sexual violence.
Key actions
1.
1 Identify a lead organisation to coordinate a multi-sectoral approach to
reduce the risk of sexual violence, ensure referrals and provide holistic
support to survivors.
•• Coordinate with other sectors to strengthen prevention and response.
2.
2 Inform the community of available services and the importance of seeking
immediate medical care following sexual violence.
•• Provide post-exposure prophylaxis for HIV as soon as possible (within 72
hours of exposure).
•• Provide emergency contraception within 120 hours.
3.
3 Establish safe spaces in healthcare facilities to receive survivors of sexual
violence and to provide clinical care and referral.
•• Display and use clear protocols and a list of patients’ rights.
•• Train healthcare workers in supportive communication, maintaining
confidentiality and protecting survivor information and data.
4.
4 Make clinical care and referral to other supportive services available for
survivors of sexual violence.
•• Ensure referral mechanism for life-threatening, complicated or severe
conditions.
•• Establish referral mechanisms between health, legal, protection, security,
psychosocial and community services.
330
Key indicators
All health facilities have trained staff, sufficient supplies and equipment for
clinical management of rape survivor services based on national or interna-
tional protocols
All survivors of sexual violence state they received healthcare in a safe and
confidential manner
All eligible survivors of sexual violence receive:

•• Post-exposure prophylaxis within 72 hours of an incident or from exposure
•• Emergency contraception within 120 hours of an incident or from
exposure
Guidance notes
Prevention of sexual violence and rape requires action across all sectors ⊕ see
WASH water supply standard 2.1 ⊕ see WASH excreta management standard 3.2
⊕ see Food security and nutrition – food assistance standard 6.3 and Livelihoods
standard 7.2; Shelter and settlement standards 2 and 3 ⊕ see Protection Principle
1 and Core Humanitarian Standard Commitments 4 and 8. ⊕ See Health systems
standard 1.1 to 1.3 for further information on making healthcare facilities safe
and providing safe care.
Clinical care, including mental healthcare and referral for survivors, must be in place
in all primary healthcare facilities and mobile teams ⊕ see Healthcare systems 1.2
and Essential healthcare standard 2.5. This includes skilled staff to provide compas-
sionate, timely and confidential treatment and counselling to all children, adults
and older people on:
•• emergency contraception;
•• pregnancy testing, pregnancy options information and safe abortion referral
to the full extent of the law;
•• presumptive treatment of STIs;
•• post-exposure prophylaxis to prevent HIV transmission ⊕ see Health
standard 2.3.3: HIV
•• prevention of hepatitis B;
•• care of wounds and prevention of tetanus; and
•• referral for further services, such as other health, psychological, legal and
social services.
Ensure equal gender distribution of healthcare workers fluent in local and

patient languages, and coach female and male chaperones and interpreters to
provide non-discriminatory and unbiased services. Train healthcare workers on
clinical care for survivors of sexual violence, focusing on supportive commu-
nication, history and examination, treatment and counselling. Where feasible
331
Health
and needed, provide training on the medico-legal system and forensic evidence
collection.
Child survivors of sexual violence: Children should be cared for by healthcare work-
ers trained in post-rape management of children. Allow children to choose the
gender of the healthcare worker. Involve specialised protection actors quickly in
all cases.
Community engagement: Work with patients and the community to improve acces-
sibility and acceptability of care and to deliver prevention programmes through-
out a crisis. Ensure confidential feedback mechanisms and swift feedback. Involve
women, men, adolescent girls and boys, and at-risk populations such as persons
with disabilities and LGBTQI groups.
Legal frameworks: Be aware of the national medico-legal system and relevant
laws on sexual violence. Inform survivors of any mandatory reporting laws that
could limit the confidentiality of the information patients disclose to healthcare
providers. This may influence their decision to continue to seek care, but must be
respected.
In many countries, induced abortion is legal under circumstances such as
rape. Where this is the case, access or referrals should be provided without
discrimination.
While addressing sexual violence is critical, forms of gender-based violence (GBV)
such as intimate partner violence, child and forced marriage and female genital
mutilation are also not only prevalent in humanitarian crises, but in some scenarios
may increase during a crisis and have significant unique health impacts (physical,
sexual, mental) on individuals that require specific responses. Other international
guidelines are increasingly recognising not only sexual violence, but these other
forms of GBV and their impacts on health ⊕ see IASC Guidelines for Integrating
Gender-Based Violence Interventions in Humanitarian Action.

HIV
People have access to healthcare that prevents transmission and reduces
morbidity and mortality due to HIV.
Key actions
1.
1 Establish and follow standard precautions and procedures for the safe and
rational use of blood transfusion.
2.
2 Provide anti-retroviral therapy (ART) to everyone who is already on it, including
women in prevention of mother-to-child transmission programmes.
•• Actively trace people living with HIV to continue treatment.
332
3.
3 Provide lubricated male condoms and, where already used by the population,
female condoms.
•• Work with leaders and the affected population to understand local use,
increase acceptance and ensure that condom distribution is culturally
appropriate.
4.
4 Offer testing to all pregnant women where HIV prevalence is greater than
1 per cent.
5.
5 Initiate post-exposure prophylaxis (PEP) as soon as possible, but within
72 hours of exposure for survivors of sexual violence and occupational
exposure.
6.
6 Provide co-trimoxazole prophylaxis for opportunistic infections for:
a. patients living with HIV; and

b. children born to mothers living with HIV, at four to six weeks of age;
continue until HIV infection is excluded.
3.
7 Ensure primary healthcare facilities have antimicrobials and provide syndro-
mic management to patients with symptoms of an STI.
Key indicators
All transfused blood is screened and is free of transfusion-transmissible
infections, including HIV
Percentage of people previously on anti-retroviral therapy (ART) who continue

to receive ART medicines
•• 90 per cent
Percentage of women accessing health services who are tested for HIV, where
HIV prevalence is greater than 1 per cent
•• 90 per cent
Percentage of individuals potentially exposed to HIV reporting to health

facilities who receive PEP within 72 hours of exposure
•• 100 per cent
Percentage of HIV-exposed infants receiving co-trimoxazole at four to six

weeks of age
•• 95 per cent
Guidance notes
The key actions above should apply in all humanitarian crises, regardless of the
local HIV epidemiology.
333
Health
Involve the affected community and key populations (healthcare workers, leaders,
women, LGBTQI people, persons with disabilities) in HIV service delivery, and
ensure they know where to access anti-retroviral (ARV) medicines. If there is
already an association of people living with HIV, consult with and involve them in
programme design and delivery.
Community-led distribution of condoms within peer groups is useful. Key
populations and adolescents will often know where their peers congregate,
and volunteers can distribute to peers. Educate key populations with cultur-
ally appropriate messages about correct use and disposal of used condoms.
Make condoms available to the community, aid agency staff, uniformed staff,
aid delivery truck drivers and others.
Blood transfusion: ⊕ See Health systems standards 1.1 and 1.3.
Post-exposure care and treatment should include counselling, HIV exposure risk
assessment, informed consent, assessment of the source, and provision of
anti-retroviral medicines. Do not give PEP to a person known to be living with
HIV. Although counselling and testing is recommended before starting PEP, if
not feasible do not delay the initiation of PEP ⊕ see Essential healthcare – sexual
and reproductive health standard 2.3.2: Sexual violence and clinical management
of rape.
Comprehensive HIV-related activities in crises: Establish the following activities
as soon as feasible:
HIV awareness: Provide accessible information to the public, particularly to popula-
tions at higher risk, about preventing HIV and other STIs.
HIV prevention: Provide high-risk populations with harm-reduction services
such as sterile injecting equipment and opioid substitution therapy for people
who inject drugs, where these services already existed ⊕ see Essential healthcare
standard 2.5: Mental health care.
HIV counselling and testing: Provide (or re-establish) counselling and testing services
linked to ART initiation. Priority groups for HIV testing are pregnant women and
their partners, children with severe acute malnutrition where the HIV prevalence is
greater than 1 per cent, and other at-risk groups.
Stigma and discrimination: It is crucial to ensure that strategies and programmes do
not increase stigma. Aim to actively decrease stigma and discrimination in areas
known to have high stigma index and discriminatory behaviours.
ART interventions: Extend anti-retroviral therapy to all who need it – not only those
who were previously enrolled – as soon as possible.
Prevention of mother-to-child transmission: Test pregnant women and their
partners and provide early infant HIV diagnosis. Provide ART to women who
Note: Caritas Internationalis and its Members do not promote the use of, or distribute any form of,
artificial birth control.
334
ESSENTIAL HEALTHCARE – Injury and trauma care
are already known to be positive for or who newly test positive for HIV. Refer
infants who test positive to paediatric HIV services. Provide infant feeding guid-
ance specific to women living with HIV, and retention and adherence support
⊕ see Food security and nutrition – Infant and young child feeding standards 4.1
and 4.2.
Services for HIV/TB co-infection: Provide TB screening and referral for people
living with HIV. Provide TB treatment to people previously enrolled on a
treatment programme ⊕ see Essential healthcare – Communicable disease
standard 2.1.3: Diagnosis and case management. Link testing services for TB and
HIV in high – prevalence settings and establish TB infection control in health-
care settings.
2.4 Injury and trauma care

In any crisis, a high burden of morbidity and mortality is attributable to injury.
Increased demand for trauma care services is likely to quickly exceed the capaci-
ties of local health systems. To reduce the impact of injuries and the risk of health
system collapse, provide systematic triage and mass casualty management
alongside basic emergency, safe operative and rehabilitative care. This section
addresses the health system response to physical injury. Specific guidance on
poisoning, mental health and sexual violence are addressed elsewhere ⊕ see
Appendix 4: Poisoning; Essential healthcare standard 2.5 and Essential healthcare –
Sexual and reproductive health standard 2.3.2.
Injury and trauma care standard 2.4:

Injury and trauma care
People have access to safe and effective trauma care during crises to prevent
avoidable mortality, morbidity, suffering and disability.
Key actions
1.
1 Provide care for trauma at all levels for all patients.
•• Quickly establish safe referral systems between facilities and from affected
communities to facilities.
•• Establish mobile clinics or field hospitals if care in fixed structures is not
accessible to the population.
2.
2 Ensure that healthcare workers have the skills and knowledge to address
injuries.
•• Include all levels from first responders to those providing definitive surgical
and anaesthetics care.
335
Health
3.
3 Establish or strengthen standardised protocols for triage and injury and
trauma care.
•• Include referral systems for child protection, survivors of sexual violence,
and those requiring mental health and psychosocial support.
4.
4 Provide tetanus prophylaxis to anyone at risk of injury, to injured people with
open wounds and those involved in rescue and clean-operations.
5.
5 Ensure minimum safety and governance standards for all facilities providing
trauma and injury care, including field hospitals.
6.
6 Ensure timely access to rehabilitation services, priority assistive devices and
mobility aids for injured patients.
•• Confirm that assistive devices such as wheelchairs and crutches or other
mobility aids can be repaired locally.
7.
7 Ensure timely access to mental health services and psychosocial support.
8.
8 Establish or strengthen the health information systems to include injury and
trauma data.
•• Prioritise basic clinical documentation such as individual medical records for
all trauma patients.
•• Use standard definitions to integrate injury into the health information
system data sets.
Key indicators
Percentage of health facilities that have a disaster plan including management
of mass casualties, reviewed and rehearsed on a regular basis
Percentage of health facilities with protocols for the acutely injured including
formal triage instruments
Percentage of health facilities with staff that have received basic training in the
approach to the acutely injured
Percentage of health facilities implementing quality improvement measures

to reduce baseline morbidity and mortality according to available data
Guidance notes
Training and skills development for injury and trauma care should include:
•• mass casualty management, for those responding and coordinating response;

•• basic first aid;
•• standardised triage in the field and at healthcare facilities; and
•• early recognition, resuscitation, wound management, pain control and
time-sensitive psychosocial support.
336
ESSENTIAL HEALTHCARE – Injury and trauma care
Standardised protocols should exist or be developed to cover the following:
•• acuity-based triage classification for routine and surge situations that

includes assessment, prioritisation, basic resuscitation and criteria for
emergency referral;
•• frontline emergency care at the point of access; and
•• referrals for emergency and advanced care, including surgery, post-
operative care and rehabilitation.
Minimum safety and quality standards: Even where trauma care is being provided
in response to an acute event or ongoing conflict, Minimum Standards must be
assured. Areas to be addressed include:
•• the safe and rational use of medications, devices and blood products,
including supply chain;
•• infection prevention and control;
•• sufficient power supply for lighting, communications and operating essential
medical devices such as emergency resuscitation equipment and sterilisation
autoclaves; and
•• medical waste management.
Community-based first aid: Timely and appropriate first aid by non-professionals

saves lives if done in a safe and systematic manner. All first aiders should use a
structured approach to the injured. Basic wound management training, such as in
cleaning and dressing, is vital.
Include household- and community-level first aid, and guidance on when and
where to seek medical help. Raise awareness of context-specific risks such as
unstable infrastructure or risk of injury during rescue attempts.
Triage is the process of categorising patients according to the severity of their
injuries and their need for care. It identifies those who would most benefit from
immediate medical intervention. Several triage systems exist. One widely used
system applies five colours: red for highest priority patients, yellow for medium,
green for lower, blue for patients beyond the technical capacity of the facility or
who require palliative care, and grey for the deceased.
Frontline professional emergency care: All higher-level healthcare workers, such
as doctors, should be skilled in a systematic approach to the acutely ill and
injured ⊕ see the ABCDE approach in the IFRC International First Aid and Resuscitation
Guidelines. Initial resuscitation and life-saving interventions, such as fluid and anti-
biotic administration, haemorrhage control and treatment of pneumothorax, can
be delivered in many settings before transferring the patient to advanced services.
Anaesthesia, trauma and surgical care: Emergency, operative and rehabilitative
care should be undertaken only by organisations with appropriate expertise.
Providers should act within their professional scope of practice, with adequate
resources to sustain their activities. Inappropriate or inadequate care may do
337
Health
more harm than doing nothing. Surgery provided without appropriate pre- and
post-operative care and ongoing rehabilitation can result in a failure to restore
functional capacities of the patient.
Field hospitals: The use of temporary field hospitals may be necessary, especially
in acute crises, and should be coordinated with MoH or lead agencies and other
health actors. Standards and safety of care should meet national and international
standards ⊕ see References for further guidance.
Rehabilitation and social reintegration: Early rehabilitation can increase survival,
maximise the impact of medical and surgical interventions and enhance quality of life
for injured survivors. Medical teams with inpatient capacity must be able to provide
early rehabilitation. Map existing rehabilitation capacities and referral pathways
and understand the links between existing social welfare systems and cash-based
assistance. Establish links with local rehabilitation centres or community-based
rehabilitation organisations for ongoing care.
Prior to discharge, consider the ongoing needs of trauma and injury patients,
including those with a pre-existing disability. Ensure medical and rehabilitation
follow-up, patient and caregiver education, essential assistive devices (such as
crutches or wheelchairs), mental health and psychosocial support, and access to
other essential services. Establish multi-disciplinary care plans and teams
including physical rehabilitation specialists and staff skilled in mental healthcare
and psychosocial support. Mental health and psychosocial support for those
with life-changing injuries should begin as when they are inpatients. Links to
ongoing support services are essential ⊕ see Essential healthcare standard 2.5:
Mental health care.
Special management considerations – pain control: Good pain management after
injury reduces the risks of pneumonia and deep vein thrombosis and helps the
patient start physiotherapy. It reduces the physiological stress response, leading to
a reduction in cardiovascular morbidity, and reduces psychological stress. Acute pain
from trauma should be treated following the reverse WHO pain ladder. Neuropathic
pain resulting from nerve injury may be present from the outset and should be treated
appropriately ⊕ see Health systems standard 1.3: Essential medicines and medical devices
and Essential healthcare standard 2.7: Palliative care ⊕ see WHO pain ladder.
Special management considerations – wound management: In most crises, many
patients will present for care more than six hours after injury. Delayed presentation
greatly increases the risk of wound infection and associated mortality. Healthcare
workers must know protocols to manage wounds (including burns) and prevent
and treat infection, for both acute and delayed presentations. These protocols
include providing appropriate antibiotics, surgical removal of foreign material and
dead tissue, and dressing.
Tetanus: In sudden-onset natural disasters the risk of tetanus can be relatively
high. Administer tetanus toxoid-containing vaccine (DT or Td – diphtheria and
338
ESSENTIAL HEALTHCARE – Mental health
tetanus vaccines – or DPT, depending on age and vaccination history) to those

with open wounds. Individuals with dirty or highly contaminated wounds should
also receive a dose of tetanus immune globulin (TIG) if they are not vaccinated
against tetanus.
2.5 Mental health

Mental health and psychosocial problems are common among adults, adoles-
cents and children in all humanitarian settings. The extreme stressors associated
with crises place people at increased risk of social, behavioural, psychological and
psychiatric problems. Mental health and psychosocial support involves multi-
sectoral actions. This standard focuses on actions by health actors ⊕ see the Core
Humanitarian Standard and Protection Principles for more information on psycho-
social interventions across sectors.
Mental health standard 2.5:

Mental health care
People of all ages have access to healthcare that addresses mental health
conditions and associated impaired functioning.
Key actions
1.
1 Coordinate mental health and psychosocial supports across sectors.
•• Set up a cross-sectoral technical working group for mental health and
psychosocial issues. It may be co-led by a health organisation and a protection
humanitarian organisation.
2.
2 Develop programmes based on identified needs and resources.
•• Analyse existing mental health systems, staff competencies, and other
resources or services.
•• Conduct needs assessments, keeping in mind that mental health conditions
may be pre-existing, induced by the crisis or both.
3.
3 Work with community members, including marginalised people, to
strengthen community self-help and social support.
•• Promote community dialogue on ways to address problems collaboratively,
drawing on community wisdom, experience and resources.
•• Preserve or support re-initiation of pre-existing support mechanisms such
as groups for women, youth and people living with HIV.
4.
4 Orient staff and volunteers on how to offer psychological first aid.
•• Apply the principles of psychological first aid to manage acute stress after
recent exposure to potentially traumatic events.
339
Health
5.
5 Make basic clinical mental healthcare available at every healthcare facility.
•• Organise brief training and supervise general healthcare workers to assess

and manage priority mental health conditions.
•• Organise a referral mechanism among mental health specialists, general
healthcare providers, community-based support and other services.
6.
6 Make psychological interventions available where possible for people
impaired by prolonged distress.
•• Where feasible, train and supervise non-specialists.
7.
7 Protect the rights of people with severe mental health conditions in the
community, hospitals and institutions.
•• Visit psychiatric hospitals and residential homes for people with severe
mental health conditions on a regular basis from early in the crisis.
•• Address neglect and abuse in institutions and organise care.
8.
8 Minimise harm related to alcohol and drugs.
•• Train staff in detection and brief interventions, harm reduction, and manage-
ment of withdrawal and intoxication.
9.
9 Take steps to develop a sustainable mental health system during early
recovery planning and protracted crises.
Key indicators
Percentage of secondary healthcare services with trained and supervised staff
and systems for managing mental health conditions
Percentage of primary healthcare services with trained and supervised staff

and systems for managing mental health conditions
Number of people participating in community self-help and social support activities
Percentage of health services users who receive care for mental health conditions
Percentage of people who have received care for mental health conditions who
report improved functioning and reduced symptoms
Number of days for which essential psychotropic medicines were not available
in the past 30 days
•• Less than four days
Guidance notes
Multi-level support: Crises affect people in different ways, requiring different
kinds of support. A key to organising mental health and psychosocial support is to
develop a layered system of complementary supports that meets different needs,
340
ESSENTIAL HEALTHCARE – mENTAL HEALTH
Specialised
services
Focused
non-specialised
supports
Strengthening
community and
family supports
Social considerations
in basic services and
security
Pyramid of multi-layered services and supports (Figure 10)

Source: IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings (2010)
as illustrated in the diagram below. This pyramid shows how different actions
complement each other. All layers of the pyramid are important and should ideally
be implemented concurrently.
Assessment : Rates of mental health conditions are substantial in any crisis.
Prevalence studies are not essential to initiate services. Use rapid participatory
approaches and, where possible, integrate mental health in other assessments.
Do not limit assessment to one clinical issue.
Community self-help and support : Engage community health workers, leaders
and volunteers to enable community members, including marginalised people, to
increase self-help and social support. Activities could include creating safe spaces
and the conditions for community dialogue.
Psychological first aid: Psychological first aid needs to be available to people
exposed to potentially traumatic events such as physical or sexual violence,
witnessing atrocities and experiencing major injuries. This is not a clinical interven-
tion. It is a basic, humane and supportive response to suffering. It includes listening
carefully, assessing basic needs and ensuring they are met, encouraging social
support and protecting from further harm. It is non-intrusive and does not press
people to talk about their distress. After brief orientation, community leaders,
healthcare workers and others involved in the humanitarian response can provide
psychological first aid to people in distress. Although psychological first aid should
be widely available, the overall mental health and psychosocial support response
should not be limited to it alone.
341
Health
Single-session psychological debriefing promotes venting by encouraging people

to briefly but systematically recount perceptions, thoughts and emotional reac-
tions experienced during a recent stressful event. It is at best ineffective and
should not be used.
Other psychological interventions: Non-specialised healthcare workers can deliver
psychological interventions for depression, anxiety and post-traumatic stress
disorder when they are well trained, supervised and supported. This includes
cognitive behaviour therapy or interpersonal therapy.
Clinical mental healthcare: Brief all health staff and volunteers about available
mental healthcare. Train health providers according to evidence-based protocols
such as the. Where possible, add a mental health professional such as a psychi-
atric nurse to general healthcare facilities. Arrange private space for consulta-
tions ⊕ see mhGAP Humanitarian Intervention Guide.
The most frequent conditions presented to health services in emergencies
are psychosis, depression and a neurological condition, epilepsy. Maternal
mental health is of specific concern because of its potential impact on care
for children.
Integrate mental health categories into the health information system ⊕ see
Appendix 2: Sample HMIS form.
Essential psychotropic medicines: Organise an uninterrupted supply of essential
psychotropic medicines with at least one from each therapeutic category
(anti-psychotic, anti-depressant, anxiolytic, anti-epileptic, and medicines to
counter side effects of anti-psychotics. ⊕ See the Interagency Emergency Health
Kit for suggested psychotropic medicines and Health systems standard 1.3: Essential
Protecting the rights of people with mental health conditions: During humanitarian
crises, people with severe mental health conditions are extremely vulnerable to
human rights violations such as abuse, neglect, abandonment and lack of shelter,
food or medical care. Designate at least one agency to address the needs of people
in institutions.
Transition to post-crisis: Humanitarian crises increase the long-term rates of
many mental health conditions, so it is important to plan for sustained increased
treatment coverage across the affected area. This includes strengthening existing
national mental health systems and fostering inclusion of marginalised groups
(including refugees) in these systems. Demonstration projects, with short-term
emergency funding, can provide proof-of-concept and create momentum to
attract further support and funds for mental health system development.
2.6 Non-communicable diseases
The need to focus on non-communicable diseases (NCDs) in humanitarian
crises reflects increased global life expectancy combined with behavioural risk
342
ESSENTIAL HEALTHCARE – Non-communicable diseases
factors such as tobacco smoking and unhealthy diets. About 80 per cent of
deaths from NCDs occur in low- or middle-income countries, and emergencies
exacerbate this.
Within an average adult population of 10,000 people, there are likely to be
1,500–3,000 people with hypertension, 500–2,000 with diabetes, and 3–8
acute heart attacks over a normal 90-day period.
Diseases will vary but often include diabetes, cardiovascular disease (including
hypertension, heart failure, strokes, chronic kidney disease), chronic lung
disease (such as asthma and chronic obstructive pulmonary disease) and
cancer.
Initial response should manage acute complications and avoid treatment inter-
ruption, followed by more comprehensive programmes.
Mental health and palliative care are specifically addressed in ⊕ Essential
healthcare standards 2.5: Mental healthcare and 2.7: Palliative care.
Non-communicable diseases standard 2.6:

Care of non-communicable diseases
People have access to preventive programmes, diagnostics and essential
therapies for acute complications and long-term management of non-
communicable diseases.
Key actions
1.
1 Identify the NCD health needs and analyse the availability of services
pre-crisis.
•• Identify groups with priority needs, including those at risk of life-
threatening complications such as insulin-dependent diabetes or
severe asthma.
2.
2 Implement phased-approach programmes based on life-saving priorities
and relief of suffering.
•• Ensure patients diagnosed with life-threatening complications
(for example, severe asthma attack, diabetic ketoacidosis) receive
appropriate care. If appropriate care is not available, offer palliative
and supportive care.
•• Avoid sudden treatment disruption for patients diagnosed before the crisis.
3.
3 Integrate NCD care into the health system at all levels.
•• Establish a referral system to manage acute complications and complex

cases in secondary or tertiary care, and to palliative and supportive care.
•• Refer patients for nutrition or food security responses where required.
343
Health
4.
4 Establish national preparedness programmes for NCDs.
•• Include essential medicines and supplies in pre-positioned or contingency

emergency medical supplies.
•• Prepare individual patients with a backup supply of medications and instruc-
tions on where to access emergency care should a crisis occur.
Key indicators
Percentage of primary healthcare facilities providing care for priority NCDs
Number of days essential medicines for NCDs were not available in the past
30 days
Number of days for which basic equipment for NCDs was not available (or not
functional) in the past 30 days
All healthcare workers providing NCD treatment are trained in NCD management
Guidance notes
Needs and risk assessment to identify priority NCDs: Design according to
context and phase of emergency. This could involve reviewing records, using
pre-crisis data, and conducting household surveys or epidemiological assess-
ment with a cross-sectional survey. Gather data regarding specific NCD
prevalence and incidence and identify life-threatening needs or severely
symptomatic conditions.
Analyse pre-crisis service availability and use, especially for complex cases such
as cancer or chronic renal disease, to assess expectations and health system
capacity in the context. The medium- to long-term aim is to support and reinstate
such services.
Complex treatment needs: Provide continuity of care for patients with complex
needs such as renal dialysis, radiotherapy and chemotherapy, if possible. Give
clear and accessible information about referral pathways. Provide referrals
to palliative care support if available ⊕ see Essential healthcare standard 2.7:
Palliative care.
Integration of NCD care into the health system: Provide basic treatment for NCDs
at primary healthcare level in line with national standards, or in line with interna-
tional emergency guidance where national standards do not exist.
Work with communities to improve early detection and referrals. Integrate CHWs
into primary care facilities, and engage with community leaders, traditional heal-
ers and the private sector. Outreach services can provide NCD health services to
isolated populations.
344
ESSENTIAL HEALTHCARE – Palliative care
Adapt the existing health information system for the crisis setting, or develop a
new one, to include monitoring of main NCDs: hypertension, diabetes, asthma,
chronic obstructive pulmonary disease, ischaemic heart disease and epilepsy
⊕ see Health systems standard 1.5: Health information and appendix 2.
Medicines and medical devices: Review the national list of essential medicines
and devices, including technologies and core laboratory tests, to manage NCDs.
Focus on primary healthcare ⊕ see Health systems standard 1.3: Essential medicines
and medical devices. If needed, advocate for the inclusion of key essential medicines
and medical devices in line with international and emergency guidance on
NCDs. Provide access to essential medicines and medical devices at the appro-
priate levels of care. NCD kits may be used in conjunction with inter-agency
emergency health kits in the early stages of the crisis to increase availability of
essential medicines and equipment. Do not use these kits to provide long-term
supplies.
Training: Train all levels of clinical staff on case management of NCD conditions
and train all staff in priority NCD management, including standard operating
procedures on referral ⊕ see Health systems standard 1.2: Health care workforce.
Health promotion and education: Provide information about NCD services and where
to access care. Information should be accessible to all, including older people and
persons with disabilities, to promote healthy behaviours, modifying risk factors,
and improving self-care and adherence to treatment. Healthy behaviours can
include regular physical activity or reducing alcohol and tobacco consumption,
for example. Work with different parts of the community to develop messages
and distribution strategies so that they are age, gender and culturally appropriate.
Adapt prevention and control strategies to the context, considering constraints
such as limited food supply or overcrowding.
Prevention and preparedness plans: Include NCD management in national disaster
and emergency plans, ensuring it is specific to the different types of healthcare
facilities (for example, small health centres or major hospitals with dialysis units).
Health centres in unstable or disaster-prone contexts should be prepared for NCD
service delivery.
Form a registry of patients with complex conditions and critical needs and create
standardised operating protocols for referring them if a crisis occurs.
2.7 Palliative care
Palliative care is the prevention and relief of suffering and distress associated with
end-of-life care. It includes identifying, assessing and treating pain as well as other
physical, psychosocial and spiritual needs. Integrate physiological, psychological
and spiritual care based solely on patient or family request, and include support
systems to help patients, families and caregivers. This end-of-life care should be
provided regardless of the cause.
345
Health
Palliative care standard 2.7:

Palliative care
People have access to palliative and end-of-life care that relieves pain and
suffering, maximises the comfort, dignity and quality of life of patients, and
provides support for family members.
Key actions
1.
1 Establish guidelines and policies to support consistent palliative care.
•• Include national or international guidelines for pain and symptom control at
healthcare facilities.
•• Develop triage guidelines based on the patient’s medical condition and
prognosis and availability of resources.
2.
2 Develop a care plan and provide palliative care to patients who are dying.
•• Ensure pain relief and dignity in death in an acute emergency, as a minimum.
•• Explore the patient’s or family’s understanding of the situation as well as
their concerns, values and cultural beliefs.
3.
3 Integrate palliative care into all levels of health system.
•• Establish strong referral networks to provide continuity of support and care.

•• Prioritise community-based management involving home-based care.
4.
4 Train healthcare workers to provide palliative care, including pain and
symptom control, and mental health and psychosocial support.
•• Meet national standards, or international standards where national
standards do not exist.
5.
5 Provide essential medical supplies and equipment.
•• Stock palliative medicines and appropriate medical devices such as inconti-

nence pads and catheters at healthcare facilities.
•• Be aware of controlled drugs regulations that may delay availability of
essential medicines.
6.
6 Work with local systems and networks to support patients, caregivers and
families in the community and at home.
•• Provide supplies for home care needs, such as incontinence pads, urinary
catheters and dressing packs.
Key indicators
Number of days for which essential palliative care medicines were not available
in the past 30 days
•• Less than 4 days
346
ESSENTIAL HEALTHCARE – Palliative care
Percentage of staff trained in basic pain and symptom control or palliative care
in each health centre, hospital, mobile clinic and field hospital
Percentage of patients identified by the healthcare system as in need that have

received end-of-life care
Guidance notes
Humanitarian health actors should be aware of and respect local ways of making
medical decisions and local values related to illness, suffering, dying and death.
Relief of suffering is important, and dying patients should receive comfort-ori-
ented care, whether their illness is from fatal injuries, infectious disease or any
other cause.
Developing a care plan: Identify relevant patients and respect their right to
make informed decisions about their care. Provide unbiased information and
take account of their needs and expectations. The care plan should be agreed
and be based on patient preferences. Offer access to mental health and
psychosocial support.
Availability of medicines: Some palliative care medicines such as pain relief are
included in the basic and supplementary modules of the inter-agency emergency
health kit, and in the Essential Medicines List. Inter-agency emergency health kits
(IEHK) are useful for early phases of a crisis but are not suitable for protracted
situations where more sustainable systems should be established ⊕ see Health
systems standard 1.3: Essential medicines and medical devices and References and
further reading.
Family, community and social support: Coordinate with other sectors to agree a
referral pathway for patients and their families to have integrated support. This
includes accessing national social and welfare systems or organisations that offer
assistance in shelter, hygiene and dignity kits, cash-based assistance, mental
health and psychosocial support, and legal assistance to ensure that basic daily
needs are met.
Coordinate with relevant sectors to trace separated families so that patients may
communicate with them.
Work with existing networks of community care, who often have trained home-
based care facilitators and community psychosocial workers, to provide additional
support for patients and family members and help provide home-based care if
required (such as for people living with HIV).
Spiritual support: All support should be based on patient or family requests. Work
with local faith leaders to identify spiritual care providers who share the patient’s
faith or belief. These providers can act as a resource for patients, carers and
humanitarian actors.
347
Health
Orient local faith leaders on key principles of psychosocial support for patients
facing major health issues.
Establish reliable mechanisms for bilateral referral between the healthcare system
and spiritual leaders for any patient, caregiver or family member who requests it.
Ensure support for safe and dignified burial practices in collaboration with the local
community, according to national or international guidance ⊕ see Health systems
standard 1.1: Health service delivery.
348
Appendix 1 – Health assessment checklist
Appendix 1
Health assessment checklist
Preparation
•• Obtain available information on the crisis-affected population.
•• Obtain available maps, aerial photos or satellite images, and geographic
information system (GIS) data of the affected area.
•• Obtain demographic, administrative and health data.
Security and access

•• Determine the existence of the ongoing natural or human-made hazards.
•• Determine the overall security situation, including the presence of armed
forces.
•• Determine the access that humanitarian organisations have to the crisis-
affected population.
Demographics and social structure
•• Determine the size of the crisis-affected population, disaggregated by sex,
age and disability.
•• Identify groups at increased risk, such as women, children, older people,
persons with disabilities, people living with HIV or marginalised groups.
•• Determine the average household size and estimates of the number of
female- and child-headed households.
•• Determine the existing social structure and gender norms, including
positions of authority and/or influence in the community and the
household.
Background health information

•• Identify health problems that existed in the crisis-affected area before the
emergency.
•• Identify pre-existing health problems in the country of origin for refugees, or
the area of origin for internally displaced persons.
•• Identify existing risks to health, such as potential epidemic diseases.
•• Identify pre-existing and existing barriers to healthcare, social norms and
beliefs, including positive and harmful practices.
•• Identify previous sources of healthcare.
•• Analyse the various aspects of the health system and their performance
⊕ see Health systems standards 1.1 to 1.5.
Mortality rates
•• Calculate the crude mortality rate.
•• Calculate the age-specific mortality rates (such as under-five mortality rate).
349
Health
•• Calculate cause-specific mortality rates.

•• Calculate proportional mortality rate.
Morbidity rates
•• Determine incidence rates of major health conditions that have public health
importance.
•• Determine age- and sex-specific incidence rates of major health conditions
where possible.
Available resources
•• Determine the capacity of the MoH of the country affected by the crisis.
•• Determine the status of national health facilities, including total number by
type of care provided, degree of infrastructure damage, and access.
•• Determine the numbers and skills of available healthcare staff.
•• Determine the available health budgets and financing mechanism.
•• Determine the capacity and functional status of existing public health
programmes such as Extended Programme on Immunisation.
•• Determine the availability of standardised protocols, essential medicines,
medical devices and equipment, and logistics systems.
•• Determine the status of existing referral systems.
•• Determine the level of IPC standards in health facilities.
•• Determine the status of the existing health information system.
Data from other relevant sectors

•• Nutritional status.
•• Environmental and WASH conditions.
•• Food basket and food security.
•• Shelter – quality of shelter.
•• Education – health and hygiene education.
350
Appendix 2 – Sample weekly surveillance reporting forms
Appendix 2
Sample weekly surveillance reporting forms
2.1 Mortality surveillance form (aggregate)*
Site: ........................................................................................................................................................
Date from Monday: ....................................... To Sunday: ............................................................
Total population at beginning of this week: .............................................................................
Births this week: ............................................ Deaths this week: ..............................................
Arrivals this week (if applicable): .............. Departures this week: ......................................
Total population at end of week: .............. Total under 5 years population: ....................
<5 Years ≥5 Years Total

Male Female Male Female
Immediate cause
Acute lower respiratory infection
Cholera (suspected)
Diarrhoea – bloody
Diarrhoea – watery
Injury – non-accidental
Malaria
Maternal death – direct
Measles
Meningitis (suspected)
Neonatal (0–28 days)
Other
Unknown
Total by age and sex
Underlying cause
AIDS (suspected)
Malnutrition
Maternal death – indirect
Non-communicable diseases (specify)
Other
Total by age and sex
*This form is used when there are many deaths and therefore more detailed information on individual deaths
cannot be collected due to time limitations.
–Other causes of mortality can be added according to context and epidemiological pattern.
–Age can be further disaggregated as feasible, for example 0–11 months, 1–4 years, 5–14 years, 15–49
years, 50–59 years, 60–69 years, 70–79 years, 80+ years.–
–Deaths should not be reported solely from health facilities, but should include reports from site and religious
leaders, community workers, women’s groups and referral hospitals.
–Whenever possible, case definitions should be put on the back of this form.
351
Health
2.2 Mortality surveillance form (individual records) *
Site: .........................................................................................................................................................
Date from Monday: ........................................ To Sunday: ...........................................................
Total population at beginning of this week: ............................................................................
Births this week: ............................................ Deaths this week: .............................................
Arrivals this week (if applicable): ............... Departures this week: ....................................
Total population at end of week: ............... Total under 5 years population: ...................
Direct cause of death Underlying

causes
Acute lower respiratory infection
Non-communicable dis. (specify)

Age (days=d, months=m, yrs=y)
Location in site (e.g. block no.)

Died in hospital or at home
Maternal death (indirect)
Maternal death – direct
Injury – non-accidental
Meningitis (suspected)
Neonatal (0-28 days)
Cholera (suspected)
Diarrhoea – watery
Diarrhoea – bloody
Date (dd/mm/yy)
AIDS (suspected)
Other (specify)
Other (specify)
Malnutrition
Unknown
Sex (m, f)
Measles
Malaria
No
*This form is used when there is enough time to record data on individual deaths; it allows analysis by age,
location and facility utilisation rates.
–Frequency of reporting (that is, daily or weekly) depends upon the number of deaths.
–Other causes of death can be added as appropriate in the situation.
–Deaths should not be reported solely from site health facilities, but should include reports from site and
religious leaders, community workers, women’s groups and referral hospitals.
–Whenever possible, case definitions should be put on the back of this form.
–Age can be further disaggregated as feasible, for example 0–11 months, 1–4 years, 5–14 years,
15–49 years, 0–59 years, >60 years.
352
2.3 Sample early warning alert and response (EWAR) early warning reporting form
This form is used in the acute phase of the crisis when the risk of public health events, such as trauma, poison-
ing, or outbreaks from epidemic-prone diseases, are high.
Date from Monday: .................................................................. To Sunday: ..............................................................................
Town/village/settlement/camp:...............................................................................................................................................
Province: ...................................................................................... District: ....................................................................................
Subdistrict: .................................................................................. Site name: ..............................................................................
• Inpatient • Outpatient • Health centre • Mobile clinic
Supporting agency(ies): ...............................................................................................................................................................
Reporting officer & contact number: ......................................................................................................................................
Total population: ....................................................................... Total under 5 years population: ...
A. WEEKLY AGGREGATE DATA
New cases of: Morbidity Mortality Total

<5 Years 5 Years <5 Years 5 Years &
and over over
TOTAL ADMISSIONS
TOTAL DEATHS
Acute respiratory infection
Acute watery diarrhoea
Acute bloody diarrhoea
Malaria – suspected/confirmed
Measles
Meningitis – suspected
Acute haemorrhagic fever syn-
drome
Acute jaundice syndrome
Acute flaccid paralysis (AFP)
Tetanus
Other fever >38.5°C
Trauma
Chemical poisoning
Others
Total
–More than one diagnosis is possible; the most important should be recorded. Each case should be counted only once.
–Include only those cases that were seen (or deaths that occurred) during the surveillance week.
–Write “0” (zero) if you had no case or death during the week for one of the syndromes listed in the form.
–Deaths should be reported only in the mortality section, NOT in the morbidity section.
–Case definitions for each condition under surveillance should be written on the back of this form.
–Causes of morbidity can be added or subtracted according to the epidemiology and risk assessment of disease.
–The purpose of EWAR surveillance is the early detection of public health events that need immediate response.
–Data on conditions such as malnutrition should be obtained through surveys (prevalence), rather than surveil-
lance (incidence).
B. OUTBREAK ALERT
At any time you suspect any of the following diseases, please SMS or phone ………………..
or email ……………... with maximum information on time, place and number of cases and
deaths: cholera, shigellosis, measles, polio, typhoid, tetanus, hepatitis A or E, dengue,
meningitis, diphtheria, pertussis, haemorrhagic fever, trauma and chemical poisoning.
This list of diseases will vary depending on the disease epidemiology of the country.
353
Health
2.4 Sample routine health management information system (HMIS)

surveillance reporting form
Site: ........................................................................................................................................................
Date from Monday: ................................................. To Sunday: ..................................................
Total population at beginning of this week/month: ..............................................................
Births this week/month: ....................................... Deaths this week/month: .....................
Arrivals this week/month (if applicable): ..................................................................................
Departures this week/month: ......................................................................................................
Total population at end of week/month: ..................................................................................
Total under 5 years population: ...................................................................................................
Morbidity Under 5 years 5 years and over Total Repeat cases

(new cases) (new cases)
Diagnosis Male Female Total Male Female Total New cases Total
Acute respiratory
infection
Acute watery
diarrhoea
Acute bloody
diarrhoea
Malaria – suspected/
confirmed
Measles
Meningitis –
suspected
Acute haemorrhagic
fever syndrome
Acute jaundice
syndrome
Acute flaccid
paralysis (AFP)
Tetanus
Other fever >38.5°C
HIV/AIDS
Eye diseases
Skin diseases
Acute malnutrition
Sexually Transmitted Infection
Genital ulcer disease
Male urethral
discharge
Vaginal discharge
Pelvic inflammatory
disease (PID)
Neonatal conjunctivitis
354
Morbidity Under 5 years 5 years and over Total Repeat cases

(new cases) (new cases)
Diagnosis Male Female Total Male Female Total New cases Total
Congenital syphili
Non-communicable diseases
Hypertension
Ischaemic heart
disease
Diabetes
Asthma
Chronic obstructive
pulmonary disease
Epilepsy
Other chronic NCD
Mental Health
Alcohol or other
substance use
disorder
Intellectual disability
and development
disorders
Psychotic disorder
(including bipolar
disorder)
Dementia or delirium
Moderate-severe
emotional disorder/
depression
Medically unex-
plained somatic
complaint
Self-harm (including
suicide attempt)
Other psychological
complaint
Injuries
Major head/spine
injury
Major torso injury
Major extremity
injury
Moderate injury
Minor injury
Total
ge can be further disaggregated as feasible, for example 0–11 months, 1–4 years, 5–14 years, 15–49 years,
A
50–59 years, >60 years
355
Health
Appendix 3
Formulas for calculating key health indicators
Crude mortality rate (CMR)
Definition: The rate of death in the entire population, including both women and
men and all ages.
Formula:
Total number of deaths

during time period
x 10,000 persons = Deaths/10,000 persons/day
Mid-period population at risk x
Number of days in time period
Under-5 mortality rate (U5MR)

Definition: The rate of death among children below five years of age in the population.
Formula:
Total number of deaths in children

<5 years during time period 10,000
x = Deaths/10,000 children under 5 years/day
Total number of children <5 years x persons
Number of day in time period
Incidence rate
Definition: The number of new cases of a disease that occur during a specified
period of time in a population at risk of developing the disease.
Formula:
Number of new cases due to

specific disease in time period New cases due to specific
x 1,000 persons =
Population at risk of developing disease/1,000 persons/month
disease x Number of months in
time period
Case fatality rate (CFR)

Definition: The number of people who die of a disease divided by the number of
people who have the disease.
Formula:
Number of people dying from

disease during time period
× 100 = x%
People who have the disease
during time period
356
Appendix 3 – Formulas for calculating key health indicators
Health facility utilisation rate

Definition: The number of outpatient visits per person per year. Whenever possible,
draw a distinction between new and old visits. New visits should be used to calcu-
late this rate. However, it is often difficult to differentiate between new and old
visits, so they are frequently combined as total visits during a crisis.
Formula:
Total number of visits in one week

x 52 weeks = Visits/person/year
Total population
Number of consultations per clinician per day

Definition: Average number of total consultations (new and repeat cases) seen by
each clinician per day.
Formula:
Total number of consultations

in one week Number of days health facility
÷
Number of FTE* clinicians open per week
in health facility
*FTE (full-time equivalent) refers to the equivalent number of clinicians working in a health facility.
For example, if there are six clinicians working in the outpatient department but two of them work
half-time, then the number of FTE clinicians = 4 full-time staff + 2 half-time staff = 5 FTE clinicians.
357
Health
Appendix 4
Poisoning
Poisoning can occur when people are exposed to toxic chemicals through the
mouth, nose, skin, eyes or ears or through ingestion. Children are at higher risk
because they breath more quickly, have a large surface area relative to body mass,
have more permeable skin, and are closer to the ground. Toxic exposures can affect
a child’s development, including causing growth retardation and impaired nutri-
tion, and can lead to illness or death.
Initial management
On presentation to the health facility, if the patient is known to have been exposed
to or has signs and symptoms of chemical exposure:
•• take precautions for healthcare staff, including wearing appropriate personal

protective equipment (PPE);
•• triage patients;
•• perform life-saving interventions;
•• decontaminate (for example, remove the patient’s clothes, or rinse affected
areas with soapy water), ideally outside the health facility to prevent further
exposures; then
•• follow further treatment protocols, including supportive treatment.
Treatment protocols
These may vary by country. In general, providing an antidote, and supportive
treatment (such as for breathing), is needed.
The table below shows symptoms of chemical exposure and common antidotes
given.
358
Appendix 4 – Poisoning
Symptoms of exposure to toxic chemicals and possible treatment

Class of toxic Common features of exposure Antidotes
chemical (country guidelines will vary)
Nerve agents Pinpoint pupils; blurred vision; Atropine
such as sarin, headache; copious secretions; tight Oximes (pralidoxime, obidoxime)
tabun or VX chest and breathing difficulty; nausea; Benzodiazepines (for seizures)
vomiting; diarrhoea; muscle twitching;
seizures; loss of consciousness.
Blister agents Tearing; eye irritation; conjunctivitis; Supportive treatment +/- sodium
such as mustard corneal damage; redness and blisters thiosulphate
gas of the skin with pain; respiratory For example, eye irrigation,
distress. topical antibiotic, skin washing,
bronchodilators,
Use sodium thiosulphate in severe
cases
Cyanide Gasping for air; asphyxiation; seizures; Amyl nitrite (first aid)
confusion; nausea. Sodium thiosulphate and sodium
nitrite or with 4 DMAP
or Hydroxocobalamin
or Dicobalt edetate
Incapacitating Dry mouth and skin; tachycardia; physostigmine
agents such altered consciousness; delusions;
as BZ hallucinations; hyperthermia;
incoordination; dilated pupils.
Tear gas and riot Stinging and burning of mucous Mainly supportive treatment
control agents. membranes; lacrimation; salivation;
runny nose; tight chest; headache;
nausea.
Chlorine Eye redness and lacrimation; nose and N acetylcysteine (NAC)
throat irritation; cough; suffocation
or choking sensation; shortness
of breath; wheezing; hoarse voice;
pulmonary oedema.
Thallium (rat Abdominal pain; nausea; vomiting; Prussian blue
poison) diarrhoea; constipation; seizures;
delirium; depression; scalp and body
hair loss; painful peripheral neuropathy
and distal motor weakness; ataxia;
neurocognitive deficits.
Lead Anorexia; vomiting; constipation; Chelation
abdominal pain; pallor; inattentive-
ness; weakness; peripheral palsies.
Organophos- Salivation; lacrimation; urination; Atropine
phates defaecation; gastric cramps; vomiting. Oximes (pralidoxime, obidoxime)
(includes some
insecticides and
nerve gas)
Modified from WHO, Environmental Health in Emergencies guidance.
359
Health

Health and human rights
The Right to Health: Fact Sheet No.31. OHCHR and WHO, 2008.
http://www.ohchr.org
Civil–military coordination
Civil Military Coordination during Humanitarian Health Action. Global Health Cluster,
2011. www.who.int
Humanitarian Civil-Military Coordination: A Guide for the Military. UN OCHA, 2014.
http://www.unocha.org
Protection and international humanitarian law

Ambulance and pre-hospital services in risk situations. ICRC, 2013. www.icrc.org
Common Ethical principles of health care in times of armed conflict and other emergen-
cies. ICRC, Geneva, 2015. https://www.icrc.org
Ensuring the preparedness and security of health care facilities in armed conflict
and other emergencies. ICRC, 2015. www.icrc.org
Guidance Note on Disability and Emergency Risk Management for Health. World
Health Organization, 2013. http://www.who.int
Health Care in Danger: The responsibilities of health care personnel working in armed
conflicts and other emergencies. ICRC, 2012. www.icrc.org
Minimum Standards for Child Protection in Humanitarian Action: Standard 24
Shelter and Child Protection. Child Protection Working Group (now the Alliance for
Child Protection in Humanitarian Action), 2012.
https://resourcecentre.savethechildren.net
Monitoring and Reporting Mechanism (MRM) on Grave Violations Against Children in
situations of Armed Conflict. UN and UNICEF, 2014. http://www.mrmtools.org
Coordination
Health Cluster Guide. Global Health Cluster, 2009. http://www.who.int
Reference module for cluster coordination at the country level. IASC, 2015.
Health in emergencies
Blanchet, K et al Evidence on public health interventions in humanitarian crises.
The Lancet, 2017: http://www.thelancet.com
Classification and Minimum Standards for foreign medical teams in sudden onset
disasters. WHO, 2013. http://www.who.int
Ensuring Access to Health Care Operational Guidance on Refugee Protection and
Solutions in Urban Areas. UNHCR, 2011. http://www.unhcr.org
360
Public Health Guide in Emergencies. The Johns Hopkins and Red Cross Red Crescent,
2008. http://pdf.usaid.gov
Refugee Health: An approach to emergency situations. Médecins Sans Frontières,
1997. http://refbooks.msf.org
Spiegel et. al. Health-care needs of people affected by conflict: future trends and
changing frameworks. The Lancet, 2010. http://www.thelancet.com
Clinical guidelines
Clinical Guidelines - Diagnosis and Treatment Manual. MSF, 2016.
http://refbooks.msf.org
Health systems
Analysing Disrupted Health Sectors. A Modular Manual. WHO, 2009.
Elston et al. Impact of the Ebola outbreak on health systems and population health in
Sierra Leone. Journal of Public Health, 2015. https://academic.oup.com
Everybody’s Business. Strengthening Health Systems to Improve Health Outcomes.
WHO, 2007. http://www.who.int
The Health System Assessment Approach: A How to Manual 2.0. USAID, 2012. www.
hfgproject.org
Parpia et al. Effects of Response to 2014-2015 Ebola Outbreak on Deaths from
Malaria, HIV / AIDS and Tuberculosis West Africa. Emerging Infection Diseases Vol 22.
CDC, 2016. https://wwwnc.cdc.gov
Recovery Toolkit: Supporting countries to achieve health service resilience. WHO, 2016.
Toolkit assessing health system capacity to manage large influx of refugees, asylum-seekers
and migrants. WHO/UNHCR/IOM, 2016. http://www.euro.who.int
Safety
Comprehensive Safe Hospital Framework. WHO, 2015. http://www.who.int
Patient Safety: Making Health Safer. WHO, 2017. http://www.who.int
Infection prevention and control

Essential environmental health standards in health care. WHO,2008.
Essential Water and Sanitation Requirements for Health Structures. MSF, 2009.
http://oops.msf.org
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings. CDC, 2007 updated 2017. https://www.cdc.gov
Guidance for the selection and use of Personal Protective Equipment (PPE) in healthcare
settings. CDC, 2004. https://www.cdc.gov
361
Health
Guidelines for safe disposal of unwanted pharmaceuticals in and after emergencies.

WHO, 1999. http://apps.who.int
Guidelines on Core Components of Infection Prevention and Control Programmes at the
National and Acute Health Care Facility level. WHO, 2016. http://www.who.int
Management of Dead Bodies after Disasters: A field Manual for First Responders,
Second Edition. ICRC, IFRC, 2016. www.icrc.org
Safe management of wastes for health-care activities, Second edition. WHO, 2014.
Healthcare workforce
Classifying health workers: mapping occupations to the international standards. WHO.
Global strategy on human resources for health. Workforce 2030. WHO, 2016.
Human resources for Health Information System, Minimum Data Set for Health
Workforce Registry. WHO, 2015. http://www.who.int
Health workforce requirement for universal health coverage and the SDGs. WHO, 2016.
International Standard Classification of Occupation: Structure, group definitions and
correspondence tables. ILO, 2012. http://www.ilo.org
WISN Workload indicators of staffing need, user’s manual. WHO, 2010.
Working together for health. World Health Report 2006. WHO 2006.
Medicines
Emergency Reproductive Health Kit. UNFPA, 2011. https://www.unfpa.org
Guidelines of Medicine Donations. WHO, 2010. http://www.who.int
Interagency Emergency Health Kit. WHO, 2015. http://www.who.int
Model Formulary for children. WHO, 2010. http://apps.who.int
Model List of Essential Medicines 20th List. WHO, 2017. http://www.who.int
Non-Communicable Diseases Kit. WHO, 2016. http://www.who.int
Revised Cholera Kits. WHO, 2015. http://www.who.int
The Interagency Emergency Health Kit 2017: Medicines and Medical Devices for 10 000
People for Approximately Three Months. WHO. 2017.
Medical devices including assistive devices

Core Medical Equipment. WHO, 2011. http://www.who.int
Decommissioning Medical Equipment and Devices. WHO http://www.who.int
Global Atlas of Medical Devices. WHO, 2017. http://www.who.int
362
Guidelines on the provision of Manual Wheelchairs in less resourced settings. World

Health Organization, 2008. http://www.who.int
Medical Device technical series: Medical device regulations, medical devices by health care
facilities, needs assessment for medical devices, procurement process resource guide,
medical device donations, medical equipment maintenance programme overview. WHO,
2011. http://www.who.int
Priority Assistive Products List. The GATE Initiative, WHO and USAID, 2016.
Controlled medicines
Access to Controlled Medications Programme, WHO Briefing Note. WHO, 2012.
Availability of Internationally Controlled Drugs: Ensuring Adequate Access for Medical
and Scientific Purposes. International Narcotics Control Board and WHO, 2010.
http://www.incb.org
Availability of narcotic drugs and psychotropic substances in emergency situations, INCD
report, pages 36-37. International Narcotics Control Board, 2014. www.incb.org
Ensuring Balance in National Policies on Controlled Substances. Guidance for availability
and accessibility of controlled medicines. WHO, 2011. http://www.who.int
Blood products
Blood safety and availability. WHO, 2017. http://www.who.int
Guidelines on management of blood and blood components as essential medicines,
Annex 3. WHO, 2017. http://apps.who.int
Universal Access to Safe Blood Transfusion. WHO, 2008. http://www.who.int
Health financing
Cash-based Interventions for Health Programmes in Refugee Settings: A Review. UNHCR,
2015. http://www.unhcr.org
Cash for Health: Key Learnings from a cash for health intervention in Jordan. UNHCR,
2015. http://www.unhcr.org
Monitoring progress towards universal health coverage at country and global levels.
WHO, 2014. http://apps.who.int
Removing user fees for primary health care services during humanitarian crises. Global
Health Cluster and WHO, 2011. http://www.who.int
Health information
IASC Guidelines: Common Operating Datasets in Disaster Preparedness and Response. IASC,
2011 https://interagencystandingcommittee.org
Global Reference List of 100 Core Health Indicators. WHO, 2015. http://www.who.int
Standards for Public Health Information Services in Activated Health Clusters and Other
Humanitarian Health Coordination Mechanisms. Global Health Cluster, 2017.
363
Health
Health needs assessments and prioritisation of health care services

Assessment Toolkit: Practical steps for the assessment of health and humanitarian crises.
MSF, 2013. http://evaluation.msf.org
Global Health Observatory Data Repository: Crude birth and death rate by country.
World Health Organization, 2017. http://apps.who.int
Rapid Risk Assessments of Acute Public Health Events. WHO, 2012.
SARA Service Availability and Readiness Assessment Survey. WHO/USAID, 2015.
Communicable disease prevention

Integrated Vector Management in Humanitarian Emergencies Toolkit. MENTOR
Initiative and WHO, 2016. http://thementorinitiative.org
Vaccination in Acute Humanitarian Crises: A Framework for Decision Making. WHO,
Communicable diseases (specific diseases)

Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control: New Edition. WHO,
Guidelines for the control for shigellosis. WHO, 2005. http://www.who.int
Interim Guidance Document on Cholera surveillance. Global Task Force on Cholera Control
and WHO, 2017. http://www.who.int
Liddle, K et al. TB Treatment in a Chronic Complex Emergency: Treatment Outcomes and
Experiences in Somalia. Trans R Soc Trop Med Hyg, NCBI, 2013.
www.ncbi.nlm.nih.gov
Managing Meningitis Epidemics in Africa. WHO, 2015. http://apps.who.int
Management of a measles epidemic. MSF, 2014. http://refbooks.msf.org
Meningitis Outbreak Response in Sub-Saharan Africa. WHO, 2014.
Pandemic Influenza Preparedness (PIP) Framework for the sharing of influenza viruses
and access to vaccines and other benefits. WHO, 2011. http://apps.who.int
Outbreak detection and early response

Early detection, assessment and response to acute public health events, Implementation
of Early Warning and Response with a focus on Event-Based Surveillance. WHO, 2014.
“Early warning, alert and response (EWAR): a key area for countries preparedness
for Health Emergencies. WHO, 2018. Weekly Epidemiological Record. WHO.
Early warning, alert and response (EWAR) a key area for countries preparedness for
Health Emergencies. WHO, 2018. http://apps.who.int
Weekly Epidemiological Record. WHO. http://www.who.int
364
Outbreak Surveillance and Response in Humanitarian Crises, WHO guidelines for EWARN
implementation. WHO, 2012. http://www.who.int

Communicable disease control in emergencies, A field Manual. WHO, 2005.
Epidemic Preparedness and Response in Refugee Camp Settings, Guidance for Public
health officers. UNHCR, 2011. http://www.unhcr.org
Outbreak Communication Planning Guideline. WHO, 2008. http://www.who.int
Child and newborn health

IMCI Chart Booklet. WHO, 2014. http://www.who.int
Integrated Community Case Management in Acute and Protracted Emergencies: case
study for South Sudan. IRC and UNICEF, 2017. https://www.rescue.org
Newborn Health in Humanitarian Settings Field Guide Interim Version. IAWG RH in
Crises, 2016. http://iawg.net
Overview and Latest update on iCCM: Potential for Benefit to Malaria Programs. UNICEF
and WHO, 2015. www.unicef.org
Polio vaccines: WHO position Paper Weekly epidemiological record. WHO, 2016.
Updates on HIV and infant feeding. UNICEF, WHO, 2016. http://www.who.int
Sexual and reproductive health

Adolescent Sexual and Reproductive Health Toolkit for Humanitarian Settings.
UNFPA and Save the Children, 2009. http://iawg.net
Inter-Agency Reproductive Health Kits for Crisis Situations, 5th Edition. UNFPA/IAWG,
2011. http://iawg.net
Inter-agency Field Manual on Sexual and Reproductive Health in Humanitarian
Settings. IWAG on Reproductive Health in Crises and WHO, 2018.
Medical eligibility criteria wheel for contraceptive use. WHO, 2015. http://who.int
Minimum Initial Service Package (MISP) for Reproductive Health in Crisis Situations:
A distance learning module. IWAG and Women’s Refugee Commission. 2011.
http://iawg.net
Selected practice recommendations for contraceptive use, Third Edition. WHO, 2016.
Safe abortion: Technical & policy guidance for health systems. WHO, 2015.
Sexual violence and clinical management of rape

Clinical Care for Sexual Assault Survivors. International Rescue Committee, 2014.
365
Health
Caring for Child Survivors of Sexual Abuse Guidelines for health and psychosocial service
providers in humanitarian settings. IRC and UNICEF, 2012. https://www.unicef.org
Clinical Management of Rape Survivors: Developing protocols for use with refugees
and internally displaced persons, Revised Edition, pp.44–47. WHO, UN Population
Fund, and UNHCR, 2004. www.who.int
Clinical Management of Rape Survivors: E-Learning. WHO 2009. http://apps.who.int
Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian
Action, Reducing Risk, promoting resilience and aiding recovery. Inter-Agency
Standing Committee, 2015. https://gbvguidelines.org
Guidelines for Medico-Legal Care of Victims of Sexual Violence. WHO, 2003.
HIV
Consolidated Guidelines on the Use or ART Drugs for Treating and Preventing HIV
Infection: Recommendations for a public health approach - Second edition. WHO, 2016.
www.who.int
Guidelines for Addressing HIV in Humanitarian Settings. UNAIDS and IASC, 2010.
http://www.unaids.org
Guidelines for the delivery of antiretroviral therapy to migrant and crisis-affected
populations in Sub Saharan Africa. UNHCR, 2014. http://www.unhcr.org
Guidelines for management of sexually transmitted infections. WHO, 2003.
www.emro.who.int
Guidelines on post-exposure prophylaxis for HIV and the use of Cotrimoxazole prophylaxis
for HIV-related infections among adults, adolescents and children. WHO, 2014.
HIV prevention in emergencies. UNFPA, 2014. http://www.unfpa.org
PMTCT in Humanitarian Settings Inter-Agency Task Team to Address HIV in Humanitarian
Emergencies Part II: Implementation Guide. Inter-Agency Task Team, 2015.
WHO policy on collaborative TB/HIV activities Guidelines for national programmes and
other stakeholders. WHO, 2012. http://www.who.int

American Heart Association Guidelines for CPR & ECC. American Heart Association,
2015 and 2017. https://eccguidelines.heart.org
Anaesthesia Handbook, Annex 3: ICRC Pain Management. Reversed WHO pain manage-
ment ladder. ICRC, 2017. https://shop.icrc.org
Child Protection in Humanitarian Action Review: Dangers and injuries. Alliance for
Child Protection in Humanitarian Action, 2016.
Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset
Minimum Technical Standards and Recommendations for Rehabilitation. WHO, 2016.
366
Disasters. WHO, 2013. http://www.who.int

eCBHFA Framework Community Based Health and First Aid. ICRC, 2017.
http://ifrc-ecbhfa.org
EMT minimum data set for reporting by emergency medical teams. WHO, 2016.
https://extranet.who.int
Guidelines for trauma quality improvement programmes. World Health Organization, 2009.
International First Aid and Resuscitation Guidelines. IFRC, 2016. www.ifrc.org
Interagency initiative comprising a set of integrated triage tools for routine, surge and
prehospital triage allowing smooth transition between routine and surge conditions.
WHO and ICRC. http://www.who.int
Recommended Disaster Core Competencies for Hospital Personnel. California
Department of Public Health, 2011. http://cdphready.org
Technical Meeting for Global Consensus on Triage. WHO and ICRC, 2017.
https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info
The European Resuscitation Council Guidelines for Resuscitation. European resuscitation
council, 2015. https://cprguidelines.eu
The WHO Trauma Care Checklist. WHO, 2016. http://www.who.int
von Schreeb, J et al. Foreign field hospitals in the recent sudden-onset disasters in Iran,
Haiti, Indonesia, and Pakistan. Prehospital Disaster Med, NCBI, 2008.
https://www.ncbi.nlm.nih.gov
War Surgery, Working with limited resources in armed conflict and other situations of
violence. International Committee of the Red Cross, 2010. https://www.icrc.org
Mental health
A faith-sensitive approach in humanitarian response: Guidance on mental health and
psychosocial programming. The Lutheran World Federation and Islamic Relief
Worldwide, 2018. https://interagencystandingcommittee.org
A Common Monitoring and Evaluation Framework for Mental Health and Psychosocial
Support in Emergency Settings. IASC, 2017. https://reliefweb.int
Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for
Humanitarian Settings. WHO and UNHCR, 2012. http://www.who.int
Building back better: sustainable mental health care after emergencies. WHO, 2013.
Facilitate community self-help and social support (action sheet 5.2) in guidelines on
Mental Health and Psychosocial Support in Emergency Settings. IASC, 2007.
Group Interpersonal Therapy (IPT) for Depression. WHO, 2016. http://www.who.int
Inter-Agency Referral Form and Guidance Note for Mental Health and Psychosocial
Support in Emergency Settings. IASC, 2017.
367
Health
mhGAP Humanitarian Intervention Guide: Clinical Management of Mental, Neurological and

Substance Use Conditions in Humanitarian Settings. WHO and UNHCR, 2015.
http://www.unhcr.org
Problem Management Plus (PM+): Individual psychological help for adults impaired by
distress in communities exposed to adversity. WHO, 2016. http://www.who.int
Psychological First Aid: Guide for Field Workers. WHO, War Trauma Foundation and
World Vision International, 2011. http://www.who.int
Psychological First Aid Training Manual for Child Practitioners. Save the Children, 2013.
Reference Group for Mental Health and Psychosocial Support in Emergency Settings in
Mental Health and Psychosocial Support in Humanitarian Emergencies: What Should
Humanitarian Health Actors Know. IASC, 2010. http://www.who.int
Disaster Risk Management for Health: Non-Communicable Diseases Fact Sheet
2011. WHO, 2011. http://www.who.int
Jobanputra, K. Boulle, P. Roberts, B. Perel, P. Three Steps to Improve Management of
Noncommunicable Diseases in Humanitarian Crises. PLOS Medicine, 2016.
http://journals.plos.org
Lozano et al. Global and regional mortality from 235 causes of death for 20 age
groups in 1990 and 2010: a systemic analysis for the Global Burden of Disease Study
2010. The Lancet, 2012. https://www.ncbi.nlm.nih.gov
NCD Global Monitoring Framework. WHO, 2013. http://www.who.int
NCDs in Emergencies – UN Interagency Task Force on NCDs. WHO, 2016.
Slama, S et al. Care of Non-Communicable Diseases in Emergencies. The Lancet, 2016.
http://www.thelancet.com
WHO Package of Essential Non-Communicable Disease Interventions, Tools for imple-
menting WHO PEN. WHO, 2009. http://www.who.int
Palliative care
Caring for Volunteers Training Manual. Psychosocial Centre IFRC, 2015.
http://pscentre.org
Disaster Spiritual Care Handbook. Disaster Services, American Red Cross, 2012.
Guidance for managing ethical issues in infectious disease outbreaks. WHO, 2016.
IASC guidelines on mental health and psychosocial support in emergency settings. IASC,
IAHPC List of Essential Medicines for Palliative Care. International Association for
Hospice and Palliative Care, 2007. https://hospicecare.com
368
Matzo, M et al. Palliative Care Considerations in Mass Casualty Events with Scarce
Resources. Biosecurity and Bioterrorism, NCBI, 2009.
Powell, RA. Schwartz, L. Nouvet, E. Sutton, B. et al. Palliative care in humanitarian
crises: always something to offer. The Lancet, 2017. http://www.thelancet.com
Palliative Care, Cancer control: knowledge into action: WHO guide for effective programmes.
WHO, 2007. http://www.who.int
Silove, D. The ADAPT model: a conceptual framework for mental health and psychoso-
cial programming in post conflict settings. War Trauma Foundation, 2013.
https://www.interventionjournal.com
Nouvet, E. Chan, E. Schwartz, LJ. Looking good but doing harm? Perceptions of short-
term medical missions in Nicaragua. Global public health, NCBI, 2016.
19th WHO Model List of Essential Medicines chapter 2 2, Medicines for pain and palliative
care. WHO, 2015. http://www.who.int
Poisoning
Initial Clinical management of patients exposed to chemical weapons. WHO, 2015.
Further reading
369
further reading
Further reading
Civil–military coordination
UN-CMCoord Field Handbook. UN OCHA, 2015. https://www.unocha.org/legacy/
what-we-do/coordination-tools/UN-CMCoord/publications
Coordination
Global Health Cluster. http://www.who.int/health-cluster/en/
Health systems
Approach to Health Systems Strengthening. UNICEF, 2016. https://www.unicef.org/
health/files/UNICEF_HSS_Approach_-_5Jun16.pdf
Health System Strengthening, from diagnosis to Planning. Action Contre Le Faim,
2017. https://www.actionagainsthunger.org/publication/2017/03/health-system-
strengthening-diagnosis-planning
Monitoring the Building Blocks of Health Systems: A handbook of indicators and their
measurement strategies. WHO, 2010. http://www.who.int/healthinfo/systems/
monitoring/en/
Newbrander et al. Rebuilding and strengthening health systems and providing basic
health services in fragile states. NCBI, Disasters, 2011. www.ncbi.nlm.nih.gov/
pubmed/21913929
Strategizing national health in the 21st century: a handbook. WHO, 2017. http://www.
who.int/healthsystems/publications/nhpsp-handbook/en/
van Olmen, J et al. Health Systems Frameworks in their Political Context: Framing
Divergent Agendas. BMC Public Health, 2012. https://bmcpublichealth.biomedcentral.
com/articles/10.1186/1471-2458-12-774
Safety
Diagnostic Errors: Education and Training, Electronic Tools, Human Factors, Medication
Error, Multi-morbidity, Transitions of care. WHO, 2016. http://apps.who.int/iris/
bitstream/handle/10665/252410/9789241511636-eng.pdf ?sequence=
1&isAllowed=y
Hospital Safety Index Guide for Evaluators, 2nd ed. WHO, 2015. http://apps.who.int/
iris/handle/10665/258966
Technical Series on Safer Primary Care: Patient engagement: Administrative
errors. WHO, 2016. http://www.who.int/patientsafety/topics/primary-care/
technical_series/en/
Medicines
Management of Drugs at Health Centre Level, Training Manual. WHO, 2004. http://
apps.who.int/medicinedocs/en/d/Js7919e/
F1
Health
Medical devices including assistive devices

Global Model Regulatory Framework for Medical Devices including in vitro diagnostic
medical devices. WHO, 2017. http://www.who.int/medical_devices/publications/
global_model_regulatory_framework_meddev/en/
List of Prequalified in vitro diagnostic products. WHO, 2011. http://www.who.int/
diagnostics_laboratory/evaluations/PQ_list/en/
Controlled medicines
Model Guidelines for the International Provision of Controlled Medicines for Emergency
Medical Care. International Narcotics Control Board, 1996. www.incb.org/
documents/Narcotic-Drugs/Guidelines/medical_care/Guidelines_emergency_
Medical_care_WHO_PSA.pdf
Health financing
Doocy et al. Cash-based approaches in humanitarian emergencies, a systematic review.
International Initiative for Impact Evaluation, 2016. http://www.3ieimpact.org/
media/filer_public/2016/05/19/sr28-qa-sr-report-cash-based-approaches.pdf
Wenjuan Wang et al. The impact of health insurance on maternal health care utilization:
evidence from Ghana, Indonesia and Rwanda. Health Policy and Planning, NCBI, 2017.
www.ncbi.nlm.nih.gov/pubmed/28365754
Health information
Checchi et al. Public Health Information in Crisis-Affected populations. A review of
methods and their use for advocacy and action. The Lancet, 2017. http://www.
thelancet.com/journals/lancet/article/PIIS0140-6736(17)30702-X/abstract
Creating a master health facility list. WHO, 2013. http://www.who.int/healthinfo/
systems/WHO_CreatingMFL_draft.pdf
Thierin, M. Health Information in Emergencies. WHO Bulletin, 2005. http://www.who.
int/bulletin/volumes/83/8/584.pdf
Health needs assessments and prioritisation of health care services

Checchi, F et al. Public health in crisis-affected population. A practical guide for decision
makers, Network Paper 61. Humanitarian Practice Network, December 2007. https://
odihpn.org/resources/public-health-in-crisis-affected-populations-a-practical-
guide-for-decision-makers/
Prioritising Health Services in humanitarian crises. Health and Education
Research Team, 2014. http://www.heart-resources.org/2014/03/prioritising-
health-activities-in-humanitarian-crises/
Waldman, R.J. Prioritising health care in complex emergencies. The Lancet, 2001.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)04568-2/
fulltext?_eventId=login
World Health Statistics, 2016: Monitoring for the SDGs. WHO, 2016. http://www.who.
int/gho/publications/world_health_statistics/2016/en/
F2
further reading
Communicable disease prevention

Vaccination in Humanitarian Emergencies, Implementation Guide. WHO, 2017. http://
www.who.int/immunization/documents/general/who_ivb_17.13/en/
Outbreak detection and early response

Checklist and Indicators for Monitoring Progress in the Development of IHR Core
Capacities in States Parties. WHO, 2013. http://www.who.int/ihr/publications/
checklist/en/
Integrated Disease Surveillance and Response Community Based Surveillance Training
Manual. WHO, 2015. http://www.afro.who.int/publications/integrated-diseases-
surveillance-and-response-african-region-community-based

Key messages for social mobilization and community engagement in intense transmission
areas, Ebola. WHO, 2014. http://www.who.int/csr/resources/publications/
ebola/social-mobilization-guidance/en/
Child and newborn health

Disaster Preparedness Advisory Council, Ensuring the Health of Children in Disasters.
Pediatrics. 2015. http://pediatrics.aappublications.org/content/early/2015/
10/13/peds.2015-3112
Hoddinott, J. Kinsey, B. Child growth in the time of drought. Oxford Bulletin of
Economics and Statistics. 2001. https://are.berkeley.edu/courses/ARE251/2004/
papers/Hoddinott_Kinsey.pdf
Including children with disabilities in humanitarian action, Health Booklet. UNICEF,
2017. http://training.unicef.org/disability/emergencies/index.html
Revised WHO classification and treatment of childhood pneumonia at health facilities,
evidence summaries. WHO, 2014. http://apps.who.int/iris/bitstream/10665/
137319/1/9789241507813_eng.pdf

Emergency Trauma Care. World Health Organization, 2017. http://www.who.int/
emergencycare/gaci/activities/en/
EMT initiative. WHO, 2017. https://extranet.who.int/emt/page/home
Global guidelines for the prevention of surgical site infection. WHO, 2016. http://www.
who.int/gpsc/ssi-prevention-guidelines/en/
Implementation Manual Surgical Safety Checklist, First Edition. WHO, World Alliance
for Patient Safety, 2008 http://www.who.int/patientsafety/safesurgery/ss_
checklist/en/
Joshi, GP et al. Defining new directions for more effective management of surgical pain
in the United States: highlights of the inaugural Surgical Pain Congress™. The American
Surgeon, NCBI, 2014. https://www.ncbi.nlm.nih.gov/pubmed/24666860
F3
Health
Malchow, Rj et al. The evolution of pain management in the critically ill trauma patient:
Emerging concepts from the global war on terrorism. Critical Care Medicine, NCBI,
2008. https://www.ncbi.nlm.nih.gov/pubmed/18594262
Providing Care for an Influx of Wounded. MSF, 2008. http://oops.msf.org/OCBLog/
content/OOPSLOGV3/LOGISTICS/operational-tools/Pocket%20guide%20to%20
Case%20Management%20of%20an%20Influx%20of%20Wounded%20OCB-v2.0-
2008.pdf/Pocket%20guide%20to%20Case%20Management%20of%20an%20
Influx%20of%20Wounded%20OCB-v2.0-2008.pdf
Mental health
Toolkit for the Integration of Mental Health into General Healthcare in Humanitarian
Settings. International Medical Corps, 2018. http://www.mhinnovation.net/
collaborations/IMC-Mental-Health-Integration_Toolkit
Action Plan for the global strategy for the prevention and control of non-communi-
cable diseases 2008/2013. WHO, 2009. http://www.who.int/nmh/publications/
9789241597418/en/
Demaio, A. Jamieson, J. Horn,R. de Courten, M. Tellier, S. Non-Communicable Diseases
in Emergencies: A Call to Action. PLOS Currents Disasters, 2013. http://currents.
plos.org/disasters/article/non-communicable-diseases-in-emergencies-a-
call-to-action/
Global Status Report on Non-communicable diseases. WHO, 2010. http://www.who.
int/nmh/publications/ncd_report2010/en/
The Management of cardiovascular disease, diabetes, asthma and chronic obstructive
pulmonary disease in Emergency and Humanitarian Settings. WHO, 2008.
Palliative care
A faith-sensitive approach in humanitarian response: Guidance on mental health and
psychosocial programming. The Lutheran World Federation and Islamic Relief
Worldwide, 2018. https://interagencystandingcommittee.org/mental-health-and-
psychosocial-support-emergency-settings/documents-public/inter-agency-faith’
Crisis Standards of Care: A Systems Framework for Catastrophic Disaster
Response. Institute of Medicine. 2012. https://www.nap.edu/catalog/13351/
crisis-standards-of-care-a-systems-framework-for-catastrophic-disaster
Ethics in epidemics, emergencies and disasters: research, surveillance and patient care:
training manual. WHO, 2015. http://apps.who.int/iris/bitstream/handle/10665/19
6326/9789241549349_eng.pdf?sequence=1
Faith Leader Toolkit. Coalition for Compassionate Care in California, 2017. http://
coalitionccc.org/tools-resources/faith-leaders-toolkit/
Knaul, F. Farmer, P.E. et al. Report of the Lancet Commission on Global Access to
Palliative Care & Pain Control. The Lancet, 2017. https://www.ncbi.nlm.nih.gov/
pubmed/29032993
F4
further reading
Poisoning
Chemical Hazards Compendium. UK Government, 2013. https://www.gov.uk/
government/collections/chemical-hazards-compendium
Emergency preparedness and Response, Fact Sheets on Specific Chemical Agents.
Center for Disease control and prevention, 2013. https://emergency.cdc.gov/
chemical/factsheets.asp
Guidelines for the Identification and Management of Lead Exposure in Pregnant and
Lactating Women. CDC, 2010. https://www.cdc.gov/nceh/lead/publications/
leadandpregnancy2010.pdf
The Public Health Management of Chemical Incidents, WHO Manual. WHO, 2009.
http://www.who.int/entity/environmental_health_emergencies/publications/
Manual_Chemical_Incidents/en/index.html
F5
A Annexes
Contents
Annex 1: Legal Foundation to Sphere.............................................................................................374
Annex 2: The Code of Conduct for the International Red Cross
and Red Crescent Movement and Non-governmental Organisations (NGOs)
in Disaster Relief......................................................................................................................................385
Annex 3: Abbreviations and Acronyms...........................................................................................393
Annexes
Annex 1
Legal Foundation to Sphere
The Humanitarian Charter sets out shared beliefs and common principles concerning
humanitarian action and responsibilities in situations of disaster or conflict, and
notes that these are reflected in international law. The following annotated list of
key documents includes the most relevant international legal instruments relating
to international human rights law, international humanitarian law (IHL), refugee
law and humanitarian action. It does not attempt to represent regional law and
developments. Further resources and web links to a number of other guidelines,
principles, standards and frameworks that support implementation are available
on the Sphere website, www.spherestandards.org. Notes are provided only for
the documents that require explanation, are newer additions, or have specific
sections concerning disaster or conflict.
The Sphere Handbook reflects specific concerns that are part of the international
legal framework. Generally, these include the right to personal safety and dignity;
freedom from discrimination; and the rights to water and sanitation, shelter, food
security and nutrition, and healthcare. While some of these rights are spelled
out in specific international covenants, they are all included in one of the general
human rights instruments on either civil and political rights or economic, social
and cultural rights.
This annex includes documents which are organised thematically in four categories:
1. Human rights, protection and vulnerability

2. Armed conflict and humanitarian assistance
3. Refugees and internally displaced persons
4. Disasters and humanitarian assistance
5. Humanitarian policy frameworks, guidelines and principles on human
rights, protection and vulnerability in emergency preparedness and
response www.spherestandards.org/handbook/online-resources
To ensure clarity about the status of each document within these categories, they
are classified as a) treaties and customary law or b) UN and other formally adopted
intergovernmental guidelines and principles.
374
Annex 1 – Legal foundation to Sphere
1. International instruments on human

rights, protection and vulnerability
The following documents relate primarily to the human rights recognised in universal
treaties and declarations. A number of key documents relating to age (children and
older people), sex and disability are also included, because these are some of the
most common bases of vulnerability in disaster or conflict.
1.1 Treaties and customary law on human rights, protection

and vulnerability
Human rights treaty law applies to states that are parties to the relevant treaty,
but customary law (for example, the prohibition on torture) applies to all states.
Human rights law applies at all times, with two possible exceptions:
•• Some limited civil and political rights may be suspended during declared
national emergencies, consistent with Article 4 of the International Covenant
on Civil and Political Rights (“derogation”).
•• During recognised armed conflicts, IHL applies first if there is any inconsist-
ency with human rights law.
1.1.1 Universal human rights

The Universal Declaration of Human Rights 1948 (UDHR), adopted by UN General
Assembly Resolution 217 A(III) of 10 December 1948. www.un.org
Comment: Proclaimed by the UN General Assembly in 1948, the UDHR

set out, for the first time, fundamental human rights to be universally
protected. It is not a treaty but is generally agreed to have become part of
customary international law. The first sentence of the preamble introduces
the concept of the “inherent dignity” of human beings as a fundamental
basis for human rights, and Article 1 states, “All human beings are born free
and equal in dignity and rights.”
International Covenant on Civil and Political Rights 1966 (ICCPR), adopted by UN

General Assembly Resolution 2200A (XXI) of 16 December 1966, entry into force
23 March 1976, United Nations, Treaty Series, vol. 999, p. 171 and vol. 1057, p. 407.
www.ohchr.org
Second Optional Protocol to ICCPR 1989 (aiming at the abolition of the death
penalty), adopted by UN General Assembly Resolution 44/128 of 15 December
1989, entry into force 11 July 1991, United Nations, Treaty Series, vol. 1642, p. 414.
www.ohchr.org
Comment: States parties to the ICCPR must respect and ensure the rights
for all individuals within their territory or under their jurisdiction, while
375
Annexes
recognising the right of “peoples” to self-determination and the equal

rights of men and women. Some rights (marked with asterisk*) may never
be suspended, even in the most dire national emergency.
ICCPR Rights: right to life;* no torture or other cruel, inhuman or degrading

treatment;* no slavery;* no arbitrary arrest or detention; humanity and
dignity in detention; no imprisonment for breach of contract;* freedom of
movement and residence; only lawful expulsion of aliens; equality before
the law, fair trial and presumption of innocence in criminal trials; no retro-
spectivity in criminal offences;* equal recognition before the law;* private
life; free thought, religion and conscience;* free opinion, expression and
peaceful assembly; freedom of association; right to marriage and family
life; protection of children; right to vote and participate in public affairs;
minorities’ right to enjoy their own culture, religion and language.*
International Covenant on Economic, Social and Cultural Rights 1966 (ICESCR),

adopted by UN General Assembly Resolution 2200A (XXI) of 16 December 1966,
entry into force 3 January 1976, United Nations, Treaty Series, vol. 993, p. 3.
www.ohchr.org
Comment: States parties agree to commit the maximum of their available

resources to “achieving progressively” the covenant rights, which are to be
enjoyed equally by men and women.
ICESCR Rights: to work; to receive just remuneration; to join trade unions;

to have social security or insurance; to family life, including protection of
mothers after childbirth and protection of children from exploitation; to an
adequate standard of living, including food, clothing and housing; to physical
and mental health; to education; and to participate in cultural life and enjoy
the benefits of scientific and cultural progress.
International Convention on the Elimination of All Forms of Racial Discrimination

1969 (ICERD), adopted by UN General Assembly Resolution 2106 (XX) of
21 December 1965, entry into force 4 January 1969, United Nations, Treaty Series,
vol. 660, p. 195. www.ohchr.org
Convention on the Elimination of All Forms of Discrimination Against Women
1979 (CEDAW), adopted by UN General Assembly Resolution 34/180 of 18
December 1979, entry into force 3 September 1981, United Nations, Treaty Series,
Convention on the Rights of the Child 1989 (CRC), adopted by UN General
Assembly Resolution 44/25 of 20 November 1989, entry into force 2 September
1990, United Nations, Treaty Series, vol. 1577, p. 3. www.ohchr.org
Optional Protocol to CRC on the Involvement of Children in Armed Conflict 2000,
adopted by UN General Assembly Resolution A/RES/54/263 of 25 May 2000,
376
entry into force 12 February 2002, United Nations, Treaty Series, vol. 2173, p. 222.
www.ohchr.org
Optional Protocol to CRC on the Sale of Children, Child Prostitution and Child
Pornography 2000, adopted by UN General Assembly Resolution A/RES/54/263
of 25 May 2000, entry into force 18 January 2002, United Nations, Treaty Series,
Comment: The CRC has almost universal state accession. It restates the
basic human rights of children and identifies when they need special
protection (for example, when separated from their families). The protocols
require positive action on specific child protection issues for states that are
parties to them.
Convention on the Rights of Persons with Disabilities 2006 (CRPD), adopted
by UN General Assembly Resolution A/RES/61/106 of 13 December 2006, entry
into force 3 May 2008, United Nations, Treaty Collection, Chapter IV, 15.
www.ohchr.org
Comment: The CRPD supports the rights of people with disabilities under
all other human rights treaties, as well as dealing specifically with aware-
ness-raising regarding persons with disabilities, non-discrimination and
accessibility of services and facilities. There is also special mention of
“situations of risk and humanitarian emergencies” (Article 11).
1.1.2 Genocide, torture and other criminal abuse of rights

Convention on the Prevention and Punishment of the Crime of Genocide 1948,
adopted by UN General Assembly Resolution 260 (III) of 9 December 1948,
entry into force 12 January 1951, United Nations, Treaty Series, vol. 78, p. 277.
www.ohchr.org
Convention against Torture and Other Cruel, Inhuman or Degrading Treatment
or Punishment 1984, adopted by UN General Assembly Resolution 39/46 of
10 December 1984, entry into force 26 June 1987, United Nations, Treaty Series,
Comment: This convention has a very high number of states parties.
The prohibition on torture is also now generally recognised as part of
customary international law. No kind of public emergency or war may be
invoked to justify torture. States must not return (refoul) anyone to a terri-
tory where the person has reasonable grounds to believe he or she would
be in danger of torture.
Rome Statute of the International Criminal Court 1998, adopted by the Diplomatic
Conference in Rome, 17 July 1998, entry into force 1 July 2002, United Nations,
Treaty Series, vol. 2187, p. 3. www.icrc.org
Comment: Article 9 of the Statute (Elements of Crimes), adopted by the

International Criminal Court (ICC) in 2002, describes in detail war crimes,
377
Annexes
crimes against humanity and genocide, thus codifying much of customary

international criminal law. The ICC can investigate and prosecute matters
referred to it by the UN Security Council (even if the accused person’s
state is not a party to the treaty), as well as crimes allegedly committed by
nationals of states parties to the treaty, or in their territory.
1.2 United Nations and other formally adopted

intergovernmental principles and guidelines on
human rights, protection and vulnerability
Madrid International Plan of Action on Ageing 2002, UN Second World Assembly
on Ageing, Madrid, 2002, endorsed by UN General Assembly Resolution 37/51 of
3 December 1982. www.ohchr.org
United Nations Principles for Older Persons 1991, UN General Assembly
Resolution 46/91 of 16 December 1991. www.ohchr.org
378
2. International instruments on armed

conflict, international humanitarian law
and humanitarian assistance
2.1 Treaties and customary law on armed conflict, interna-
tional humanitarian law and humanitarian assistance
International humanitarian law (IHL) specifies the thresholds of when violent
conflict becomes “armed conflict” and thus makes this special legal regime appli-
cable. The International Committee of the Red Cross (ICRC) is the official reposi-
tory of the IHL treaties and provides extensive information and resources on its
website, including the official commentary on the Geneva Conventions and their
Protocols, and the rules of the Customary International Humanitarian Law Study.
www.icrc.org
2.1.1 Core IHL treaties

The Four Geneva Conventions of 1949
Protocol Additional to the Geneva Conventions, Protection of Victims of International
Armed Conflicts 1977 (Protocol I)
Protocol Additional to the Geneva Conventions, Protection of Victims of
Non-International Armed Conflicts 1977 (Protocol II). www.icrc.org
Comment: The four Geneva Conventions – to which all states are parties
and which are also generally accepted as part of customary law – concern
protection and treatment of the wounded and sick in land warfare (I) and at
sea (II), treatment of prisoners of war (III) and protection of civilians during
armed conflict (IV). They apply primarily to international armed conflicts,
except for Article 3 common to the conventions which concerns non-
international conflicts, and some other elements now accepted as custom-
ary law in non-international conflicts. The two 1977 protocols updated
the conventions at that time, especially the definitions of combatants
and codifying of non-international conflicts. A number of states have not
acceded to the protocols.
2.1.2 Treaties on restricted weapons, landmines and cultural property

In addition to the “Geneva law” outlined above, there is also the body of law often
described as the “Hague law” on armed conflict. This includes the convention
on protection of cultural property and a number of conventions on the types of
weapons that are restricted or prohibited, including gases and other chemical
and biological weapons, conventional weapons that are indiscriminate or cause
unnecessary suffering, as well as anti-personnel landmines and cluster munitions.
www.icrc.org
379
Annexes
2.1.3 Customary IHL

Customary IHL refers to the law of armed conflict that is accepted by states,
through their statements, policies and practices, as representing customary rules
that apply to all states, regardless of their accession to the IHL treaties. There is
no agreed list of customary rules, but the most authoritative interpretation is the
study below.
Customary International Humanitarian Law (CIHL) Study, ICRC, Henckaerts, J-M.
and Doswald-Beck, L., Cambridge University Press, Cambridge and New York,
2005. www.icrc.org
Comment: The study covers almost the full ambit of the law of armed conflict.
It lists 161 specific rules and whether each applies in international armed
conflict and/or non-international armed conflict. While some legal
commentators criticise its methodology, the CIHL study emerged from a
broadly consultative and rigorous research process over ten years, and its
authority as a collection and interpretation of the customary rules is widely
recognised.
2.2 UN and other formally adopted intergovernmental

principles and guidelines on armed conflict,
IHL and humanitarian assistance
UN Security Council “Aide Memoire” on Protection 2002, as updated 2003
(S/PRST/2003/27). undocs.org
Comment: This is not a binding resolution on states, but a guidance docu-

ment for the UN Security Council relating to peacekeeping and urgent situ-
ations of conflict, resulting from consultations with a range of UN agencies
and inter-agency standing committees (IASC).
UN Security Council resolutions on sexual violence and women in armed conflict,

especially the first such resolution, number 1325 (2000) on women, peace and
security, which was a milestone in addressing violence against women in situations
of armed conflict, and subsequently Res. 1820 (2008), Res. 1888 (2009), Res.
1889 (2009) and Res. 1325 (2012). All UN Security Council resolutions by year and
number are available at: www.un.org
380
3. International instruments on refugees

and internally displaced persons (IDPs)
3.1 Treaties on refugees and IDPs
In addition to the international treaty, this section includes two African Union
(formerly Organization of African Unity, or OAU) treaties, because they both set
historic precedents.
Convention relating to the Status of Refugees 1951 (as amended), adopted by
the United Nations Conference of Plenipotentiaries on the Status of Refugees and
Stateless Persons, Geneva, 2 to 25 July 1951, entry into force 22 April 1954, United
Nations, Treaty Series, vol. 189, p. 137. www.unhcr.org
Protocol Relating to the Status of Refugees 1967, noted by the UN General
Assembly, in Resolution 2198 (XXI) 2 of 16 December 1966, United Nations, Treaty
Series, vol. 606, p. 267. www.unhcr.org
Comment: The first international agreement on refugees, the Convention

defines a refugee as a person who, “owing to a well-founded fear of
being persecuted for reasons of race, religion, nationality, membership
of a particular social group or political opinion, is outside the country of
his nationality, and is unable to or, owing to such fear, is unwilling to avail
himself of the protection of that country or return there because there is a
fear of persecution…”
OAU Convention Governing the Specific Aspects of Refugee Problems in Africa,

1969, adopted by the Assembly of Heads of State and Government at its Sixth
Ordinary Session, Addis Ababa, 10 September 1969. www.unhcr.org
Comment: This accepts and expands the 1951 Convention definition to

include people who have been compelled to leave their country not only
as a result of persecution but also owing to external aggression, occupa-
tion, foreign domination or events seriously disturbing public order. It also
recognises non-state groups as perpetrators of persecution and it does
not require that refugees show a direct link between themselves and the
future danger.
African Union Convention for the Protection and Assistance of Internally

Displaced Persons in Africa (Kampala Convention) 2009, adopted by a Special
Summit of the African Union, held in Kampala, entry into force 6 December 2012.
au.int/en/treaties/african-union-convention-protection-and-assistance-inter-
nally-displaced-persons-africa
Comment: This is the first multilateral convention concerning IDPs.
381
Annexes
3.2 UN and other formally adopted intergovernmental

principles and guidelines on refugees and IDPs
Guiding Principles on Internal Displacement 1998, recognised in September 2005
by heads of state and governments assembled at the World Summit in New York in
UN General Assembly Resolution 60/L.1 (132, UN Doc. A/60/L.1) as “an important
international framework for the protection of internally displaced persons”.
www.ohchr.org
Comment: These principles are based on international humanitarian and

human rights law and analogous refugee law, and are intended to serve
as an international standard to guide governments, international organi-
sations and all other relevant actors in providing assistance and protection
to IDPs.
382
4. International instruments on disasters and

humanitarian assistance
4.1 Treaties on disasters and humanitarian assistance
Convention on the Safety of United Nations and Associated Personnel 1994,
adopted by UN General Assembly Resolution 49/59 of 9 December 1994, entry
into force 15 January 1999, United Nations, Treaty Series, vol. 2051, p. 363.
Optional Protocol to the Convention on the Safety of United Nations and
Associated Personnel 2005, adopted by UN General Assembly Resolution
A/60/42 of 8 December 2005, entry into force 19 August 2010, United Nations,
Treaty Series, vol. 2689, p.59. www.un.org
Comment: In the Convention, protection is limited to UN peacekeeping

unless the UN has declared “exceptional risk” – an impractical require-
ment. The Protocol corrects this major flaw in the Convention and expands
the legal protection to all UN operations, from emergency humanitarian
assistance to peacebuilding and the delivery of humanitarian, political and
development assistance.
Tampere Convention on the Provision of Telecommunication Resources for

Disaster Mitigation and Relief Operations 1998, approved by the Intergovernmental
Conference on Emergency Telecommunications 1998, entry into force 8 January
2005, United Nations, Treaty Series, vol. 2296, p. 5. www.itu.int
UN Framework Convention on Climate Change 1992 (UNFCCC), adopted by the
United Nations Conference on Environment and Development, Rio de Janeiro, 4 to
14 June 1992, welcomed by the UN General Assembly in Resolution 47/195 of
22 December 1992, entry into force 21 March 1994, United Nations, Treaty Series,
vol. 1771, p. 107. unfccc.int
•• Kyoto Protocol to the UNFCCC 1997, adopted at the third session of the
Conference of the Parties (COP-3) to the Framework Convention, Kyoto,
Japan, 1997, entry into force 16 February 2005, United Nations, Treaty
Series, vol. 2303, p. 148. unfccc.int
•• Paris Agreement 2015, adopted at the 21st session of the Conference
of the Parties to the Framework Convention (COP-21), Paris, France,
December 2015, entry into force November 2016. unfccc.int
Comment: The UNFCCC, the Kyoto Protocol and the Paris Agreement are
all part of one treaty framework. They address the urgent need for imple-
menting climate change adaptation and risk reduction strategies, and
building local capacity and resilience, especially in countries that are prone
to natural disasters. They emphasise disaster reduction strategies and risk
management, especially with regard to climate change.
383
Annexes
4.2 UN and other formally adopted intergovernmental princi-

ples and guidelines on disasters and humanitarian assistance
Strengthening of the coordination of humanitarian emergency assistance of
the United Nations, with Annex, Guiding Principles, General Assembly Resolution
46/182 of 19 December 1991. www.unocha.org
Comment: This led to the creation of the UN Department of Humanitarian
Affairs, which became the UN Office for the Coordination of Humanitarian
Affairs (OCHA) in 1998.
Sendai Framework for Disaster Risk Reduction 2015–2030 (Sendai Framework).
www.unisdr.org
Comment: The Sendai Framework is the successor instrument to the

Hyogo Framework for Action (HFA) 2005–2015: Building the Resilience of
Nations and Communities to Disasters. It was adopted by declaration at the
2015 Third UN World Conference on Disaster Risk Reduction, and endorsed
by the UN General Assembly (in Resolution 69/283). The United Nations
Office for Disaster Risk Reduction (UNISDR) supports implementation. It is
a 15-year voluntary non-binding agreement with the goal to substantially
reduce disaster risk and losses in lives, livelihoods and health.
Guidelines for the domestic facilitation and regulation of international disaster

relief and initial recovery assistance, (IDRL Guidelines) 2007, adopted by the 30th
International Conference of the Red Cross and Red Crescent (which includes states
parties to the Geneva Conventions). www.ifrc.org
384
5. Humanitarian policy frameworks,

guidelines and principles on human rights,
protection and vulnerability in emergency
preparedness and response
There is now a range of generalist and specific operational guidance on human-
itarian response in emergencies. As these tools no longer distinguish between
armed conflict, refugee situations and disaster response, a selection are provided
here under the thematic headings of: general standards; gender equality and
protection from gender-based violence; children in emergencies; and refugees
and internally displaced persons (IDPs).
1. Sphere companion standards

Minimum Standards for Child Protection in Humanitarian Action (CPMS).
Alliance for Child Protection in Humanitarian Action (The Alliance), 2012.
Minimum Standards for Education: Preparedness, Response, Recovery.
Inter-Agency Network for Education in Emergencies (INEE), 2010.
http://s3.amazonaws.com
Minimum Economic Recovery Standards (MERS). The Small Enterprise Education
and Promotion Network (SEEP), 2017. https://seepnetwork.org
Humanitarian inclusion standards for older people and people with disabilities.
Age and Disability Consortium, HelpAge International, Handicap International,
2018. https://reliefweb.int
2. Other codes, guidance and manuals by theme

2.1 General protection and quality standards in humanitarian response
Code of Conduct for The International Red Cross and Red Crescent Movement
and Non-Governmental Organisations (NGOs) in Disaster Relief ⊕ see Annex 2.
Fundamental Principles of the International Red Cross and Red Crescent
Movement 1965, adopted by the 20th International Conference of the Red Cross.
www.ifrc.org
IASC Operational Guidelines on the Protection of Persons in Situations of Natural
Disasters. Inter-Agency Standing Committee and Brookings–Bern Project on
Internal Displacement. 2011. https://www.brookings.edu
Annexes
IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings

2007. UN Inter-Agency Standing Committee. www.who.int
IASC Guidelines on Inclusion of Persons with Disabilities in Humanitarian Action.
IASC Policy on Protection in Humanitarian Action 2016. UN Inter-Agency
Standing Committee. https://interagencystandingcommittee.org
Principles and Good Practice of Humanitarian Donorship 2003, endorsed by the
Stockholm conference of donor countries, UN agencies, NGOs and the International
Red Cross and Red Crescent Movement, and signed by the European Commission
and 16 states. www.ghdinitiative.org
Professional Standards for Protection Work. 2018. International Committee of
the Red Cross (ICRC). https://shop.icrc.org
International Law and Standards Applicable in Natural Disaster Situations
(IDLO Legal Manual) 2009, International Development Law Organization (IDLO).
https://www.sheltercluster.org
2.2 Gender equality and protection from gender-based violence (GBV)

GBV Constant Companion. Global Shelter Cluster, GBV in Shelter Programming
Working Group. 2016. https://sheltercluster.org
Gender Handbook in Humanitarian Action 2006, “Women, Girls, Boys & Men,
Different Needs – Equal Opportunities, a Gender Handbook for Humanitarian
Action”. Inter-Agency Standing Committee. http://www.unhcr.org
Gender Preparedness Camp Planning: Settlement Planning, Formal Camps,
Informal Settlements Guidance. Global Shelter Cluster, GBV in Shelter
Programming Working Group. 2016. https://www.sheltercluster.org
IASC Guidelines for Integrating Gender-based Violence Interventions in
Humanitarian Action. 2015. New York; UN Inter-Agency Standing Committee and
Global Protection Cluster. www.gbvguidelines.org
Integrating Gender-Sensitive Disaster Risk Management into Community-
Driven Development Programs. Guidance Notes on Gender and Disaster Risk
Management. No.6. World Bank. 2012. https://openknowledge.worldbank.org
Making Disaster Risk Reduction Gender-Sensitive: Policy and Practical
Guidelines. Geneva; UNISDR, UNDP and IUCN. 2009. https://www.unisdr.org
Need to Know Guidance: Working with Men and Boy Survivors of Sexual and
Gender-Based Violence in Forced Displacement. UNHCR. 2011.
www.globalprotectioncluster.org
Need to Know Guidance: Working with Lesbian, Gay, Bisexual, Transgender and
Intersex Persons in Forced Displacement. UNHCR. 2011.
www.globalprotectioncluster.org
Predictable, Preventable: Best Practices for Addressing Interpersonal and Self-
Directed Violence During and After Disasters. Geneva; IFRC, Canadian Red Cross.
2012. www.ifrc.org
2.3 Children in emergencies

Field Handbook on Unaccompanied and Separated Children. 2017. Inter-agency
Working Group on Unaccompanied and Separated Children; Alliance for Child
Protection in Humanitarian Action. https://reliefweb.int
IASC Minimum Standards for Child Protection in Humanitarian Action. 2012.
New York; UN Inter-Agency Standing Committee and Global Protection Cluster
(Child Protection Working Group). cpwg.net
Inter-agency Guiding Principles on Unaccompanied and Separated Children. 2004.
ICRC, UNHCR, UNICEF, World Vision International, Save the Children UK and the
International Rescue Committee. https://www.icrc.org
2.4 Refugees and internally displaced persons (IDPs)

UNHCR (the UN Refugee Agency) has a special legal mandate for the protection
of refugees under the Refugee Convention and Protocol. UNHCR has extensive
resources on its website. www.unhcr.org
IASC Handbook for the Protection of Internally Displaced Persons (March 2010).
UN Inter-Agency Standing Committee. 2010. www.unhcr.org
Annex 2 – Code of Conduct
Annex 2
The Code of Conduct for the
International Red Cross and Red Crescent
Movement and Non-governmental
Organisations (NGOs) in Disaster Relief
Prepared jointly by the International Federation of Red Cross and Red Crescent
Societies and the International Committee of the Red Cross1
Purpose
This Code of Conduct seeks to guard our standards of behaviour. It is not about
operational details, such as how one should calculate food rations or set up a
refugee camp. Rather, it seeks to maintain the high standards of independence,
effectiveness and impact to which disaster response NGOs and the International
Red Cross and Red Crescent Movement aspires. It is a voluntary code, enforced
by the will of the organisation accepting it to maintain the standards laid down in
the Code.
In the event of armed conflict, the present Code of Conduct will be interpreted and
applied in conformity with international humanitarian law.
The Code of Conduct is presented first. Attached to it are three annexes, describing
the working environment that we would like to see created by Host Governments,
Donor Governments and Inter-governmental Organisations in order to facilitate
the effective delivery of humanitarian assistance.
Definitions
NGOs: NGOs (Non-Governmental Organisations) refers here to organisations,
both national and international, which are constituted separately from the govern-
ment of the country in which they are founded.
NGHAs: For the purposes of this text, the term Non-Governmental Humanitarian
Agencies (NGHAs) has been coined to encompass the components of the
International Red Cross and Red Crescent Movement – The International
Committee of the Red Cross, The International Federation of Red Cross and Red
Crescent Societies and its member National Societies – and the NGOs as defined
1
Sponsored by: Caritas Internationalis,* Catholic Relief Services,* International
Federation of Red Cross and Red Crescent Societies,* International Save the
Children Alliance,* Lutheran World Federation,* Oxfam,* World Council of Churches,*
International Committee of the Red Cross (* members of the Steering Committee for
Humanitarian Response).
385
Annexes
above. This code refers specifically to those NGHAs who are involved in disaster
response.
IGOs: IGOs (Inter-Governmental Organisations) refers to organisations constituted
by two or more governments. It thus includes all United Nations Agencies and
regional organisations.
Disasters: A disaster is a calamitous event resulting in loss of life, great human
suffering and distress, and large scale material damage.
The Code of Conduct

Principles of Conduct for The International Red Cross and Red Crescent Movement and
NGOs in Disaster Response Programmes
1. The humanitarian imperative comes first
The right to receive humanitarian assistance, and to offer it, is a fundamental human-
itarian principle which should be enjoyed by all citizens of all countries. As members
of the international community, we recognise our obligation to provide humanitarian
assistance wherever it is needed. Hence the need for unimpeded access to affected
populations is of fundamental importance in exercising that responsibility. The prime
motivation of our response to disaster is to alleviate human suffering amongst those
least able to withstand the stress caused by disaster. When we give humanitarian aid
it is not a partisan or political act and should not be viewed as such.
2. Aid is given regardless of the race, creed or nationality of the recipients and
without adverse distinction of any kind. Aid priorities are calculated on the
basis of need alone
Wherever possible, we will base the provision of relief aid upon a thorough assess-
ment of the needs of the disaster victims and the local capacities already in place to
meet those needs. Within the entirety of our programmes, we will reflect consider-
ations of proportionality. Human suffering must be alleviated whenever it is found;
life is as precious in one part of a country as another. Thus, our provision of aid will
reflect the degree of suffering it seeks to alleviate. In implementing this approach,
we recognise the crucial role played by women in disaster-prone communities
and will ensure that this role is supported, not diminished, by our aid programmes.
The implementation of such a universal, impartial and independent policy, can only
be effective if we and our partners have access to the necessary resources to
provide for such equitable relief, and have equal access to all disaster victims.
3. Aid will not be used to further a particular political or religious standpoint
Humanitarian aid will be given according to the need of individuals, families and
communities. Not withstanding the right of NGHAs to espouse particular political or
religious opinions, we affirm that assistance will not be dependent on the adher-
ence of the recipients to those opinions. We will not tie the promise, delivery or
distribution of assistance to the embracing or acceptance of a particular political
or religious creed.
386
4. We shall endeavour not to act as instruments of government foreign policy

NGHAs are agencies which act independently from governments. We therefore
formulate our own policies and implementation strategies and do not seek to
implement the policy of any government, except in so far as it coincides with our
own independent policy. We will never knowingly – or through negligence – allow
ourselves, or our employees, to be used to gather information of a political,
military or economically sensitive nature for governments or other bodies that may
serve purposes other than those which are strictly humanitarian, nor will we act
as instruments of foreign policy of donor governments. We will use the assistance
we receive to respond to needs and this assistance should not be driven by the
need to dispose of donor commodity surpluses, nor by the political interest of any
particular donor. We value and promote the voluntary giving of labour and finances
by concerned individuals to support our work and recognise the independence of
action promoted by such voluntary motivation. In order to protect our independence
we will seek to avoid dependence upon a single funding source.
5. We shall respect culture and custom

We will endeavour to respect the culture, structures and customs of the communities
and countries we are working in.
6. We shall attempt to build disaster response on local capacities

All people and communities – even in disaster – possess capacities as well as
vulnerabilities. Where possible, we will strengthen these capacities by employing
local staff, purchasing local materials and trading with local companies.
Where possible, we will work through local NGHAs as partners in planning and
implementation, and co-operate with local government structures where appro-
priate. We will place a high priority on the proper co-ordination of our emergency
responses. This is best done within the countries concerned by those most
directly involved in the relief operations, and should include representatives of
the relevant UN bodies.
7. Ways shall be found to involve programme beneficiaries in the management

of relief aid
Disaster response assistance should never be imposed upon the beneficiaries.
Effective relief and lasting rehabilitation can best be achieved where the intended
beneficiaries are involved in the design, management and implementation of the
assistance programme. We will strive to achieve full community participation in
our relief and rehabilitation programmes.
8. Relief aid must strive to reduce future vulnerabilities to disaster as well as

meeting basic needs
All relief actions affect the prospects for long-term development, either in a
positive or a negative fashion. Recognising this, we will strive to implement
relief programmes which actively reduce the beneficiaries’ vulnerability to
387
Annexes
future disasters and help create sustainable lifestyles. We will pay particular
attention to environmental concerns in the design and management of relief
programmes. We will also endeavour to minimise the negative impact of
humanitarian assistance, seeking to avoid long-term beneficiary dependence
upon external aid.
9. We hold ourselves accountable to both those we seek to assist and those
from whom we accept resources
We often act as an institutional link in the partnership between those who wish to
assist and those who need assistance during disasters. We therefore hold ourselves
accountable to both constituencies. All our dealings with donors and beneficiaries
shall reflect an attitude of openness and transparency. We recognise the need to
report on our activities, both from a financial perspective and the perspective
of effectiveness. We recognise the obligation to ensure appropriate monitoring of
aid distributions and to carry out regular assessments of the impact of disaster
assistance. We will also seek to report, in an open fashion, upon the impact of our
work, and the factors limiting or enhancing that impact. Our programmes will be
based upon high standards of professionalism and expertise in order to minimise
the wasting of valuable resources.
10. In our information, publicity and advertising activities, we shall recognise

disaster victims as dignified humans, not hopeless objects
Respect for the disaster victim as an equal partner in action should never be
lost. In our public information we shall portray an objective image of the disaster
situation where the capacities and aspirations of disaster victims are highlighted,
and not just their vulnerabilities and fears. While we will cooperate with the
media in order to enhance public response, we will not allow external or internal
demands for publicity to take precedence over the principle of maximising overall
relief assistance. We will avoid competing with other disaster response agencies
for media coverage in situations where such coverage may be to the detriment
of the service provided to the beneficiaries or to the security of our staff or the
beneficiaries.
The working environment

Having agreed unilaterally to strive to abide by the Code laid out above, we present
below some indicative guidelines which describe the working environment
we would like to see created by donor governments, host governments and
the inter-governmental organisations – principally the agencies of the United
Nations – in order to facilitate the effective participation of NGHAs in disaster
response.
These guidelines are presented for guidance. They are not legally binding, nor do
we expect governments and IGOs to indicate their acceptance of the guidelines
through the signature of any document, although this may be a goal to work to in
the future. They are presented in a spirit of openness and cooperation so that our
partners will become aware of the ideal relationship we would seek with them.
388
Annex I: Recommendations to the governments of disaster

affected countries
1. Governments should recognise and respect the independent, humanitarian
and impartial actions of NGHAs
NGHAs are independent bodies. This independence and impartiality should be
respected by host governments.
2. Host governments should facilitate rapid access to disaster victims for NGHAs
If NGHAs are to act in full compliance with their humanitarian principles, they should
be granted rapid and impartial access to disaster victims, for the purpose of
delivering humanitarian assistance. It is the duty of the host government, as part
of the exercising of sovereign responsibility, not to block such assistance, and to
accept the impartial and apolitical action of NGHAs. Host governments should facilitate
the rapid entry of relief staff, particularly by waiving requirements for transit, entry
and exit visas, or arranging that these are rapidly granted. Governments should grant
over-flight permission and landing rights for aircraft transporting international relief
supplies and personnel, for the duration of the emergency relief phase.
3. Governments should facilitate the timely flow of relief goods and information
during disasters
Relief supplies and equipment are brought into a country solely for the purpose
of alleviating human suffering, not for commercial benefit or gain. Such supplies
should normally be allowed free and unrestricted passage and should not be subject
to requirements for consular certificates of origin or invoices, import and/or export
licences or other restrictions, or to importation taxation, landing fees or port charges.
The temporary importation of necessary relief equipment, including vehicles, light
aircraft and telecommunications equipment, should be facilitated by the receiving
host government through the temporary waving of licence or registration restrictions.
Equally, governments should not restrict the re-exportation of relief equipment at the
end of a relief operation.
To facilitate disaster communications, host governments are encouraged to
designate certain radio frequencies, which relief organisations may use in-country
and for international communications for the purpose of disaster communications, and
to make such frequencies known to the disaster response community prior to the
disaster. They should authorise relief personnel to utilise all means of communication
required for their relief operations.
4. Governments should seek to provide a coordinated disaster information and

planning service
The overall planning and coordination of relief efforts is ultimately the responsibility
of the host government. Planning and coordination can be greatly enhanced if
NGHAs are provided with information on relief needs and government systems
for planning and implementing relief efforts as well as information on potential
389
Annexes
security risks they may encounter. Governments are urged to provide such
information to NGHAs.
To facilitate effective coordination and the efficient utilisation of relief efforts, host
governments are urged to designate, prior to disaster, a single point-of-contact for
incoming NGHAs to liaise with the national authorities.
5. Disaster relief in the event of armed conflict

In the event of armed conflict, relief actions are governed by the relevant provi-
sions of international humanitarian law.
Annex II: Recommendations to donor governments

1. Donor governments should recognise and respect the independent, humani-
tarian and impartial actions of NGHAs
NGHAs are independent bodies whose independence and impartiality should be
respected by donor governments. Donor governments should not use NGHAs to
further any political or ideological aim.
2. Donor governments should provide funding with a guarantee of operational

independence
NGHAs accept funding and material assistance from donor governments in the
same spirit as they render it to disaster victims; one of humanity and independ-
ence of action. The implementation of relief actions is ultimately the responsibility
of the NGHA and will be carried out according to the policies of that NGHA.
3. Donor governments should use their good offices to assist NGHAs in obtaining
access to disaster victims
Donor governments should recognise the importance of accepting a level of
responsibility for the security and freedom of access of NGHA staff to disaster
sites. They should be prepared to exercise diplomacy with host governments on
such issues if necessary.
Annex III: Recommendations to inter-governmental

organisations
1. IGOs should recognise NGHAs, local and foreign, as valuable partners
NGHAs are willing to work with UN and other inter-governmental agencies to
effect better disaster response. They do so in a spirit of partnership which respects
the integrity and independence of all partners. Inter-governmental agencies
must respect the independence and impartiality of the NGHAs. NGHAs should be
consulted by UN agencies in the preparation of relief plans.
2. IGOs should assist host governments in providing an overall coordinating

framework for international and local disaster relief
NGHAs do not usually have the mandate to provide the overall coordinating frame-
work for disasters which require an international response. This responsibility
390
falls to the host government and the relevant United Nations authorities. They
are urged to provide this service in a timely and effective manner to serve the
affected state and the national and international disaster response community.
In any case, NGHAs should make all efforts to ensure the effective co-ordination
of their own services.
In the event of armed conflict, relief actions are governed by the relevant provisions
of international humanitarian law.
3. IGOs should extend security protection provided for UN organisations, to

NGHAs
Where security services are provided for inter-governmental organisations,
this service should be extended to their operational NGHA partners where it is so
requested.
4. IGOs should provide NGHAs with the same access to relevant information as
is granted to UN organisations
IGOs are urged to share all information, pertinent to the implementation of effective
disaster response, with their operational NGHA partners.
391
Annex 3 – Abbreviations and acronyms
Annex 3
Abbreviations and Acronyms
ART anti-retroviral therapy
BMI body mass index
CBA cash-based assistance
CDC Centers for Disease Control and Prevention
CHS Core Humanitarian Standard on Quality and Accountability
CHW community health worker
cm centimetre
CMR crude mortality rate
CPMS Child Protection Minimum Standards
CRPD Convention on the Rights of Persons with Disabilities
DPT diphtheria, pertussis and tetanus
EPI Expanded Programme on Immunization
EWAR Early warning alert and response
FANTA Food and Nutrition Technical Assistance
FAO Food and Agriculture Organization of the United Nations
FRC free residual chlorine
GBV gender-based violence
HMIS health management information system
HWTSS household-level water treatment and safe storage
IASC Inter-agency standing committee
iCCM Integrated Community Case Management
ICCPR International Covenant on Civil and Political Rights
ICRC International Committee of the Red Cross
IDP internally displaced person
IFRC International Federation of Red Cross and Red Crescent Societies
IHL international humanitarian law
IMCI integrated management of childhood illness
INEE Inter-Agency Network for Education in Emergencies
IPC infection prevention and control
IYCF infant and young child feeding
km kilometre
LEGS Livestock Emergency Guidelines and Standards
LGBTQI Lesbian, gay, bisexual, trans, queer, intersex
LLIN long-lasting insecticide-treated net
MAM moderate acute malnutrition
MEAL monitoring, evaluation, accountability and learning
MERS Minimum Economic Recovery Standards
MISMA Minimum Standard for Market Analysis
MOH ministry of health
393
Annexes
MSF Médecins sans Frontières (Doctors without Borders)

MUAC mid upper arm circumference
NCDs non-communicable diseases
NGO non-governmental organisation
NTU nephelometric turbidity units
OAU Organization of African Unity (now African Union)
OCHA United Nations Office for the Coordination of Humanitarian Affairs
OHCHR Office of the United Nations High Commissioner for Human Rights
PEP post-exposure prophylaxis
PPE personal protective equipment
RNI reference nutrient intakes
SEEP Small Enterprise Education and Promotion (Network)
STIs sexually transmitted infections
TB tuberculosis
U5CMR under-5 crude mortality rate
UN United Nations
UNFPA United Nations Population Fund
UNHCR Office of the United Nations High Commissioner for Refugees (UN
Refugee Agency)
UNICEF United Nations Children’s Fund
WASH water supply, sanitation and hygiene promotion
WFH weight for height
WFP World Food Programme
WHO World Health Organization
394
I Index
Index
hygiene promotion 101
A auditing 84
abattoir waste 130
abbreviations 393
abuse 61. See also gender-based violence; see also B
protection; see also sexual exploitation and bathing facilities 109
abuse (SEA) beneficiaries, involvement 387
acceptability blood products 306
food security 196 blood transfusions 334
healthcare workers 304 bottled water 109
access breastfeeding 180, 190
food 199 breastmilk substitutes 190
humanitarian assistance 40 building codes 264
justice systems 44 building materials 264
legal support 44
settlements/shelter 252
toilets 115
water 105
C
accountability camps. See communal settlements
general 388 caregivers, food assistance 201
Minimum Standards 10 care plans 347
references/further reading 85 case fatality rates (CFR) 319, 321, 356
acronyms 393 cash-based assistance
admission criteria checklist 22
feeding programmes 225 general 9
malnutrition management 175, 179 references/further reading 26, 86
adults. see also people WASH 156
malnutrition 226 CFR (case fatality rates) 319, 321, 356
adverse events 302 checklists
aedes mosquito-transmitted diseases 314 food security 219
AIDS. See HIV/AIDS hygiene promotion 139
aid workers. See staff members; See community livelihoods 219
health workers (CHWs); See healthcare nutrition assessment 223
workers seed security assessment 221
air pollution 327 solid waste management 143
anaesthesia 337 vector control 142
anthropometric surveys 170 WASH general 139
anti-retroviral therapies 334 water supply 140
armed conflicts children. see also healthcare; see also infants and
disaster relief 390 young children
guidelines 380 faeces 115
legal provision 30 feeding 185, 327
treaties and customary laws 379 feeding, artificial 187, 190
artificial feeding, infants and young children 187, feeding, reference/further reading 3
190, 203 gender-based violence 192
artificial lighting 260 healthcare 322
ART interventions 334 illnesses 324
ARV interventions 334 malnutrition 225
assessments protection 12, 327
mental health conditions 341 references/further reading 3, 86
NCDs 344 separated 327
references/further reading 86 sexual violence 332
shelter and settlement planning 247 vaccination 322, 323
at-risk groups WASH 98
food assistance 200 chlorine solutions 135
food security 167, 195 cholera 321
397
INDEX
CHS. See Core Humanitarian Standard on Quality contamination, water 111

and Accountability (CHS) controlled drugs 306
CHWs (community health workers) 304, 318 coordination
climate, living spaces 256 civil-military 18, 72
CMR (crude mortality rates) 292, 325, 356 cross-sectoral 72
Code of Conduct humanitarian response 70
Core Principles 6, 386 joint distributions 101
overview 385 partner organisations 73
collaboration 71, 75, 189 references/further reading 86
collaborative learning 75 coping strategies 168
communal facilities 250, 276 Core Humanitarian Standard on Quality and
communal settlements Accountability (CHS)
general 18 appropriateness and relevance 54
solid waste management 128 communication, participation and feedback 63
vector control 122 complaints mechanisms 66
communal toilets 118 coordination and complimentarity 70
communal tools 265 effectiveness and timeliness 56
communicable diseases food security and nutrition 163
diagnosis and case management 317 general 5, 52
general 311 learning and innovation policies 73
outbreak preparedness and response 319 links to right on adequate shelter 244
prevention 312 links to right to timely and appropriate
surveillance, outbreak detection and early healthcare 294
response 314 links to right to water and sanitation 95
communication. see also information local capacities and negative effects 59
communications staff members 76
ethical 64, 66 structure 52
feeding practices 186 corruption 81, 83
general 63, 65 cost of diet 168
organisational responsibilities 64 crime reduction 252
vector control 125 criminal abuse of rights 377
WASH 98 crude mortality rates (CMR) 292, 325, 356
communities cultural properties 379
complaints mechanisms 66 culture/customs 256, 387
first aid 337
resilience 61
solid waste management 129 D
tensions 214 data. See information
community engagement dead management 137, 302
environmental management 218 debris removal 248
health care 300 delivery. see also distribution
malnutrition 175 food 204, 208
outbreak response 131 desludging 119
protection mechanisms 40, 42 diagnosing
sexual violence 332 communicable diseases 317
vector control 125 micronutrient deficiencies 183
WASH 92 diarrhoea 144, 318, 326
community health workers (CHWs) 304, 318. dignity
see also healthcare workers right to 29
community support safeguarding 38, 388
mental health 341 diphtheria 321
structures 195 disabled persons. See persons with disabilities
WASH 98 disaggregation, of data 12, 56, 310
companion standards 7 disaster information and planning service 389
complainants 69 disasters
complaints 66, 90 definition 386
complementarity 70 guidelines 384
complicity, violation of rights 39 treaties 383
confidentiality 66, 310 discharge criteria, malnutrition management 179
construction, shelters 262 diseases. see also HIV/AIDS; see also infections;
consumption see also outbreaks of diseases
energy 272 aedes mosquito-transmitted 314
398
INDEX
cholera 321 essential services 250, 276

communicable 311 evaluation
diarrhoea 144, 318, 326 Minimum Standards 10
diphtheria 321 references/further reading 87
faecal-oral transmission 144 evictions 268
hepatitis 321 EWAR (Early Warning Alert and Response) 309,
measles 323 315, 353
meningitis 320 excreta management
non-communicable 342 access to and use of toilets 115
pertussis 321 checklist 141
pneumonia 326 collection, transport, disposal and treatment 119
polio 321, 324 general 113, 136
tuberculosis 318 infections 148
viral haemorrhagic fever 320 phasing 114
water- and sanitation-related 147 reference/further reading 153
yellow fever 321 exit strategies
disinfection, water 111 food security 195
displaced people 247. see also internally displaced general 60, 61
persons (IDPs) Expanded Programme on Immunization (EPI)
disposal 322, 324
excreta 119, 141 exploitation 61. see also sexual exploitation and
medicines 306 abuse (SEA)
waste 126
distribution
dry rations 206 F
essential medicines 306 facilities. see also toilets
food 204, 208 communal 250, 276
household items 260 incontinence 103
information 207 washing/bathing 109
points 207 faecal-oral transmission, diseases 144
safety during 101, 207 family duties 217
scheduling 207 family planning 329
wet rations 206 F diagram 144
documentation 44 feedback
do no harm concept 268 humanitarian response 63
donor governments 390 organisational responsibilities 65
drainage feeding assessments 170
rainfall and floodwater 252 field hospitals 338
waste water 109 financial assistance, food production 213
drinking water 99 fire safety 252
drugs, controlled 306 first aid 337, 341
flow, relief goods/information 389
food
E access 199
Early Warning Alert and Response (EWAR) 309, choices 203
315, 353 deliveries 204, 208
end of life care. See palliative care distributions 204, 208
energy hygiene 209
consumption 272 packaging 202
food production 213 preparation/processing 204, 209
supply 260 quality 201
environment rations 199, 206
food security 167, 195 storage 209, 215
host population 276 use 200, 208, 209
humanitarian response 19, 62 food assistance
natural resources 81, 82 cash and vouchers 210
reference/further reading 87 general 197
settlements/shelter 270 nutrition requirements 198
vector control 123 targeting 205
EPI (Expanded Programme on Immunization) food production
322, 324 energy 213
erosion 272 financial assistance 213
399
INDEX
monitoring 214 financing 307

price fluctuations 213 food assistance 200
seasonality 213 general 297
strategies 212 health care delivery 298
supply chains 214 healthcare workers 302
food security NCD care 344
acceptability 196 public health data 308
assessments 165, 166 support and development 293
checklist 219 hepatitis 321
essential concepts 160 high-risk groups, vector control 125
general 193 HIV/AIDS
linked to other rights 162 children 327
forecasting, essential medicines 305 food assistance 200
fortification, food products 182 infant feeding 191
fraud 83 malnutrition management 180
fuel 260 overview 332
protection risks 15
HMIS (health management information systems)
G 309, 354
gender 13, 87 host communities 248
gender-based violence host governments 70, 389
further reading 47 household duties 217
household items 258
general 14
artificial lighting 260
references/further reading 87
checklist 276
genocide, treaties 377
distribution 260
gifts-in-kind 83
household-level water treatment and safe storage
governments. See host governments;
(HWTSS) 112, 150
See donor governments
household toilets 118
guidance notes 7
housing, land and property rights 47
human excreta. see also excreta management
H definition 113
humanitarian assistance
handwashing 99, 118 access 40
harm. see also do no harm concept cash-based assistance 22
avoidance of exposure 38 guidelines 384
healthcare. see also health systems right to receive 30, 386
acceptability 300 safety 39
checklist 349 treaties 383
children 322 Humanitarian Charter
delivery 298 commitment 31
essential 311 common principles 29
essential concepts 292 general 5, 374
financing 307 overview 28
injury and trauma care 335 humanitarian organisations
linked to other rights 293 complaint mechanisms 68, 69
mental health 339 constraints 58
non-communicable diseases 342 decision-making 59
palliative care 345 innovation policies 73
sexual and reproductive health 327 knowledge management 76
special considerations to protect 295 learning 73, 92
WASH 131 monitoring 59, 85
waste 136 policies to prevent negative effects 62
healthcare workers 302, 310. See also community humanitarian response
health workers (CHWs) appropriateness 54, 85
health indicators 356 communication 63
health information systems 309 complaints 66
health management information systems (HMIS) complementarity 70
309, 354 coordination 70
health surveillance systems 309 effectiveness 56, 86
health systems. see also healthcare feedback 63
essential medicines and medical devices 304 impartiality 40, 55, 386
400
INDEX
independence from governments 387 confidentiality 66, 310

local capacities 59, 387 disaggregation 12, 56, 310
military forces 18, 72 distributions 207
negative effects 59 flow 389
operational setting 16 nutrition assessment 169
participation 63, 65 organisational responsibilities 64
people-centred 87 personal 61, 62
politics 386 public health 308
relevance 54 sensitivity 40, 43
religion 386 sharing 65, 71, 73
timeliness 56, 86 information systems
human resources systems 56 health 309
human rights health management 309, 354
guidelines 378 nutrition and food security 167
treaties and customary laws 375 informed consent 65
hygiene. see also hygiene promotion injuries
food 209 and trauma care 335
items 99 from sharps 301
menstrual 102, 118, 152 Integrated Community Case Management
hygiene promotion (ICCM) 326
checklist 139 Integrated Management of Childhood Illness
hygiene items 99 (IMCI) 326
incontinence 102 inter-governmental organisations (IGOs)
menstrual hygiene 102 difinition 386
overview 96 recommendations 390
references/further reading 152 internally displaced persons (IDPs)
guidelines 382
I treaties on 381
International Code of Marketing of Breastmilk
ICCM (Integrated Community Case Substitutes 187
Management) 326 international humanitarian law
IDPs. See internally displaced persons (IDPs) guidelines 380
IGOs (inter-governmental organisations) treaties 379
definition 386 international law. see also international
recommendations 390 humanitarian law
IMCI (Integrated Management of right to adequate shelter 244
Childhood Illness) 326 right to timely and appropriate healthcare 294
impartiality, humanitarian response 40, 55, 386 right to water and sanitation 94
implementation intra-house food use 209
cash-based assistance 22 IPC (infection prevention and control) 135, 155, 301
shelter and settlement 247 IYCF-E assessment 189
supply chain management 24
incontinence 102, 153
incremental tenure 268 J
infant feeding joint distributions 101
artificial 187 justice systems 44
breastfeeding 180
complementary 190
HIV 191 K
malnutrition measuring 225 key actions 6
multi-sectorial support 187 key indicators 7
overview 185 knowledge management 76
infant formula 190
infants and young children. see also infant feeding
faeces 115 L
illnesses 324 laboratory testing 318
vaccination 322, 323 landmines 47, 379
infections. see also tuberculosis (TB) learning
prevention and control (IPC) 135, 155, 301 collaboration 75
respiratory 318 humanitarian organisations 73, 92
information. See also communications legal foundation, Sphere 374
accessibility 43 legal frameworks, sexual violence 332
401
INDEX
legal support 44 implementation 10

LGBTIQI people 15 MEAL 10
livelihoods programme design 9
checklist 219 right to adequate food 160
general 211 right to be free from hunger 160
income and employment 215 strategy development 9
primary production 211 use in context 8
settlements 253, 276 monitoring
living spaces 254 cash-based assistance 23
local actors, support 16 food access 199
local capacities 59, 387 food delivery 208
local leadership 60, 61 food distributions 208
logistics 26 food production 214
food use 200, 209
general 59
M malnutrition management 176
malaria Minimum Standards 10
prevention 125, 314 organisational responsibilities 85
treatment 124 references/further reading 87
malnutrition. see also nutrition; see also supply chain management 25
undernutrition violations 42
general 172 monitoring, evaluation, accountability and learning
managing 172, 173, 177, 6 (MEAL) 10
measuring 225 morbidity rates 350
management. See supply chain management; mortality rates 349. see also crude mortality rates
See knowledge management; See dead (CMR); see also EWAR (Early Warning Alert
management; See excreta management; See and Response)
solid waste management; See malnutrition: mortality surveillance 351
managing; See wound management mother-to-child transmission, HIV 334
market analysis
food security assessment 168
references/further reading 26 N
response analysis 20 national actors, support 16
market-based programming natural resources 272
general 9, 20 negative effects
household items 260 abuse 61
hygiene items 101 humanitarian response 59
references/further reading 26 newborn care 326, 328
water 108 NGHAs. See non-governmental humanitarian
market waste 130 agencies (NGHAs)
maternal care 328 NGOs (non-governmental organisations) 385
MEAL (monitoring, evaluation, accountability and non-communicable diseases (NCDs) 342
learning) 10 non-displaced households 247
measles 323 non-governmental humanitarian
medical devices 304, 306, 345 agencies (NGHAs)
medicines definition 385
availability 347 general 389, 390
essential 304, 345 non-governmental organisations (NGOs) 385
psychotropic 342 nutrition. see also malnutrition
meningitis 320 assessment 165, 169, 223
menstrual hygiene 102, 118, 152 essential concepts 160
mental health quality 199
overview 339 requirements 198, 231
psychosocial support 15, 3, 180 WASH 155
references/further reading 4 nutrition manuals 5
micronutrients
deficiencies 182, 191, 228
military forces 18, 72 O
mine actions 47 obstetrics 328
Minimum Standards 6 older people
assessment and analysis 9 food assistance 200
general 31 further reading 47
402
INDEX
malnutrition 227 pneumonia 326

protection 13 poisoning 358, 5
organisational responsibilities polio 321, 324
appropriateness and relevance humanitarian politics 386
response 55 PPE (personal protective equipment) 137, 301
collaboration 71 pre-crisis data, food security
communication 64 assessment 167
complaints 67 preparation/processing, food 209
effectiveness and timeliness 58 prequalified kits 306
feedback 65 prevention. see also vaccination
information 64 communicable diseases 312
learning policies 74 HIV 334
monitoring 85 infections 135, 155, 301
negative effects of humanitarian response 61 malaria 125, 314
resources management 81 malnutrition 174
staff members 77 micronutrient deficiencies 183
organisations. See humanitarian organisations risk assessments 313
outbreaks of diseases privacy 256
alerts 353 private sector
control 319 humanitarian response 72
detection 315 livelihood protection 218
investigations 316 procurement, essential medicines 305
responses 131 Professional Standards for Protection Work 45
thresholds 316 programme design. see also
WASH 154 market-based programming
cash-based assistance 22
malnutrition management 174, 178
P Minimum Standards 9
pain control 338 supply chain management 24
palatability, water 111 protection
palliative care 345, 4 activities 37
participation children 12, 327
humanitarian response 63, 65 HIV/AIDS patients 15
shelter construction 263 LGBTIQI people 15
partner organisations 73 living spaces 256
patients mechanisms 40, 42
adverse events 302 older people 13
rehabilitation 338 persons with disabilities 14
rights 300 references/further reading 47, 88
social reintegration 338 right 30
payments 217 WASH 152
people. See also children; see also older people; see also Protection Principles
persons with disabilities; see also infants and application 37
young children; see also people on the move food security and nutrition 163
definition 10 general 5, 36
rights of, with mental health conditions 342 links to rights to adequate shelter 244
people on the move links to right to timely and appropriate
solid waste generation 127 healthcare 294
WASH 99 links to right to water and sanitation 95
performance indicators, malnutrition protracted crises 17
management 179 proxy measures, food security
personal protective equipment (PPE) 137, 301 assessment 168
persons with disabilities psychological interventions 341
food assistance 200 psychosocial support 15, 180
malnutrition measuring 227 psychotropic medicines 342
protection 14 public health risks, WASH 92
references/further reading 47, 86 purchasing powers 217
pertussis 321
planning
location and settlement 249 Q
shelter and settlement 246 quality
solid waste management 129 food 201
403
INDEX
healthcare workers 304 risks

nutrition 199 security 214
water 109, 135 undernutrition 223
quantities vector control 122
toilets 146 WASH 97
water 107, 135, 145 rural areas 273
R S
rape 330 safeguarding
rapid responses, nutrition assessment 170 dignity 38
rations 199, 206 personal information 61, 62
recipient goverments. See host governments rights 38
recycling, waste 128, 272 safety. see also safeguarding
refugees distributions 101, 207
treaties 381 fire 252
registration processes, food assistance 206 healthcare facilities 301
rehabilitation, patients 338 healthcare workers 310
religion household items 260
humanitarian response 386 humanitarian assistance 39
palliative care 347 living spaces 256
reproductive health. See sexual and reproductive public buildings 265
health settlements 240, 253
resources. see also natural resources toilets 117
excreta as 120 trauma care 337
management 80 vaccines 324
respiratory infections 318 water chain 110
response analysis 20 work 217
restricted weapons 379 safety-net measures, livelihoods 216
return, displaced people 248 schools, WASH 104
reuse security, right 30
solid waste 128 seeds 214, 221
waste 272 selection, essential medicines 305
rights separated children 327
claiming 43 settlement scenarios
complicity in violation 39 characteristics 280
patients 300 descriptions 278
safeguarding 38 post-crisis 242
right to adequate food 160, 163 settlements/shelter
right to adequate shelter access 252
general 240 assistance options 282
links to Core Humanitarian Standard 244 checklist 274
links to international law 244 crime reduction 252
links to other rights 242 decommissioning and handover 253
links to Protection Principle 244 energy supply 260
right to be free from hunger 160 environment 270
right to life with dignity 29 essential services and facilities 250
right to protection and security 30 fire safety 252
right to receive humanitarian assistance 30, household items 258
40, 386 implementation options 247, 285
right to seek asylum or sanctuary 31 key concepts 240
right to timely and appropriate healthcare livelihoods 248, 253, 276
links to Core Humanitarian Standard 294 living space 254
links to international law 294 operation and maintenance 253
links to Protection Principles 294 planning 246, 249
right to water and sanitation 92 safety 240, 253
international law 94 site planning 251
linked to other rights 94 site selection 122, 272
links to Core Humanitarian Standard 95 surface areas 251
links to Protection Principles 95 technical assistance 262
reference/further reading 151 tenure 266
risk assessments, disease prevention 313 thermal comfort 260
404
INDEX
urban areas 241

sexual and reproductive health T
general 327 targeting, food assistance 205
HIV 332 TB (tuberculosis) 318
sexual violence 330 tenure
sexual exploitation and abuse (SEA) definition 267
by staff members 62 security 266
complaint mechanisms 68, 69 thermal comfort 260
sexual violence 330 timeliness 56
shelter. See settlements/shelter toilets
site access 115
planning 251 communal 118
selection 122, 272 household 118
social reintegration, patients 338 promotion 99
solid waste management quantities 146
checklist 143 use of word 113
community level 129 torture 377
household and personal actions 128 transition strategies
overview 126 food security 195
reference/further reading 154 general 60
Sphere 4, 374 transparency 84
Sphere Handbook traumas. See injuries
chapters 5 treatment
general 4 malaria 124
staff members malnutrition 174
behaviour and codes of conduct 70 micronutrient deficiencies 184
competencies 77, 79 water 153
conflicts of interest 83 treatment needs, complex 344
exploitation and abuse by 61 treatment protocol 318
policies 77, 78, 79 triage 337
sexual exploitation and abuse by 62 tuberculosis (TB) 318
skills development 79
support for 76
volunteers 78 U
well-being 78, 80
undernutrition. see also malnutrition
stakeholders. See host governments;
causes 160
See humanitarian organisations
interpreting levels of 171
standards. see also Minimum Standards
risks 223
links with other standards 7
vulnerable groups 162
structure 6
Universal Health Coverage 2030 307
storage
urban areas
essential medicines 306
food 209, 215 challenges 17, 162
water 100, 108, 112 health responses 293
strategies. see also exit strategies; see also transition natural resources 273
strategies; See also coping strategies settlement and shelter 241
development 9 solid waste management 127
supplementary feeding programmes 177 WASH 93
supplementation, micronutrients 182
supplies
incontinence 103 V
menstrual hygiene 103 vaccination
supply chain management 23, 26 campaigns 313, 320
support. See also community support children 322, 323
infant and young child feeding 187 infants and young children 322, 323
legal 44 vector control
local actors 16 biological and non-chemical control 123
national actors 16 checklist 142
palliative care 347 environmental engineering measures 123
psychosocial 15, 180 general 121
staff members 76 household and personal level 124
surgical care 337 living spaces 257
405
INDEX
malaria treatment 124 post-delivery contamination 111

national and international protocols 124 protected source 111
reference/further reading 154 quality 109, 135, 154
settlement level 121 quantities 107, 135, 145
ventilation 257 round-trip and queuing time 108
violations, monitoring 42 source selection 106
viral haemorrhagic fever 320 storage 100, 108, 112
volunteers 78 supply 140
vulnerabilities 10, 56, 387 systems and infrastructure 108
vulnerable groups treatment 153
references/further reading 5 Water Supply, Sanitation and Hygiene
undernutrition 162 Promotion (WASH)
approaches 94
cash-based assistance 156
W checklist 139
WASH. See Water Supply, Sanitation and Hygiene essential concepts 92
Promotion (WASH) excreta control 113
washing facilities 109 health care 131
waste. See also excreta management; see also hygiene promotion 96
market waste; see also solid waste impact on health 151
management nutrition 155
abattoir 130 programming 151
recycling 272 protection 152
reuse 272 risks 97
waste handlers 127 solid waste management 126
water vector control 121
access 105 water supply 105
bottled/treated 109 wholegrain cereals 203
chlorine solutions 135 women, pregnant and breastfeeding 189
containers 100, 108 wound management 338
contamination 111
disinfection 111
faecal material 114 Y
infections 147 yellow fever 321
measurement 107 young children. See infants and young children
palatability 111 youths, construction activities 263
406

Sphere Handbook 2018 en

Uploaded by

Copyright:

Available Formats

Sphere Handbook 2018 en

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Sphere Handbook 2018 en

Uploaded by

Copyright:

Available Formats

What is Sphere and what is its purpose?

What is Sphere and what is its purpose?

What are some of the core areas covered by Sphere standards?

What are some of the core areas covered by Sphere standards?

The

Humanitarian Charter and Minimum Standards

THE Humanitarian Charter

Core Humanitarian Standard

Water SUPPLY, Sanitation and Hygiene Promotion

Food Security and Nutrition

Shelter and Settlement

First edition 2000

Copyright © Sphere Association, 2018

ISBN 978-1-908176-400 PBK

Designed by: Non-linear Design Studio, Milan, Italy

Martin McCann Christine Knudsen

Vulnerabilities, capacities and operational settings

Sphere Board (May 2018)

Handbook revision team

Sphere Focal Points which organised in-person revision

*Individual focal points

Water Supply, Food Security Shelter and Health

ANNEX 1 Legal foundation to Sphere

Four foundation chapters and four technical chapters

•• Water Supply, Sanitation and Hygiene Promotion (WASH)

The Code of Conduct: 10 Core Principles

1. The humanitarian imperative comes first.

The Minimum Standards promote a consistent approach

The structure of the standards

•• Key indicators serve as signals to measure whether the standard is

Working with the key indicators

•• Process indicators check whether a minimum requirement has been

Links with other standards

the Humanitarian Standards Partnership and their partner organisations’

•• Livestock Emergency Guidelines and Standards (LEGS): LEGS Project

2. Using the standards in context

•• the setting in which humanitarian response is being delivered;

Culture, language, the capacity of responders, security, access, environmental condi-

The standards apply throughout the programme cycle

Assessment and analysis

Strategy development and programme design

assistance can be used to meet multi-sector needs as well as sector-specific

Monitoring, evaluation, accountability and learning

Understanding vulnerabilities and capacities

Assess current situation and trends over time

––Who is affected? ––Protection threats ––Stakeholders and ––Available goods

Analyse and prioritise

Review options and decide how the response will be delivered

Consider available options From these, select response options

Design a programme built on quality and accountability

Essential lenses Communication Monitoring context, Transition and exit

Understanding context to apply the standards (Figure 1)

Sex Disability Age

Persons with disabilities

People living with and affected by HIV

clinical interventions – are important, but do not necessarily have to be provided

Understanding the operational setting

Supporting national and local actors

The state’s role in leading or coordinating a response will be shaped by many

The standards include a view on the implications of information and communi