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HEALTH CLUSTER FORUM

23-27 March 2015 Hammamet, Tunisia

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EXECUTIVE SUMMARY

The 3rd Health Cluster Forum was convened on 23-27 March 2015, to update Health Cluster Coordinators and team members on strategic and technical developments; to share good practice and lessons learned; to review the level of support provided to Country Health Clusters and to strengthen linkages between the Global and Country Health Clusters, Regional Offices and Headquarters. The Forum was held following a two-year gap, during a period of unprecedented demand for global emergency health response and much anticipated change within WHO to strengthen its emergency response capacity in light of WHO Executive Board deliberations on the Ebola outbreak response, including as Cluster Lead Agency, following recent investment in the expanded Global Health Cluster Unit. The 5-day Forum was organised around the theme of ‘Health Cluster Coordination throughout the Humanitarian Programme Cycle (HPC): towards improved accountability’. Over the first 3 days, Health Cluster Coordinators shared their experience and challenges around each HPC component including information for strategic decision-making; strategic response planning; implementing and monitoring the response, monitoring health cluster performance; the role of clusters in preparedness; cluster transition and de-activation. Additional sessions on cluster co-ordination models and strengthening service delivery offered lessons learned on contemporary policy concerns. This was followed by two-day training on the role of Health Cluster Coordinators on ‘Plans, Programmes and Strategies’ and ‘Resource Mobilization’. The Forum format provided the Health Cluster Coordinators and team members the opportunity to present their cluster experience and perspectives through a series of informal presentations, group work and plenary discussions. In addition, an online survey was completed, and one-to-one interviews and focus group discussions held with senior management to elicit feedback on their specific technical, operational and professional concerns. Common themes emerging included lack of resources to adequately staff cluster and fulfil the 6 core cluster functions; the challenge of double-hatting; technical guidance, administrative system constraints; limited opportunities for professional growth, training and mentoring. Most of these echo issues that were raised during the 2013 Forum. Whilst many of the recommendations from the 2013 Forum are currently being implemented, this feedback highlights the need for accelerated action by the Global Health Cluster and WHO at all levels of the organisation. Summary of the Main Recommendations:

1. Clarify the roles and responsibilities for emergency health response (to all hazards) within WHO at all levels, including better alignment between the Global Health Cluster, Foreign Medical Teams, Global Outbreak Alert and Response Network and Standby partners.

2. Strengthen capacity building support in emergency response and cluster coordination for

WHO and partner staff at regional and country level.

3. Improve WHO Country Representative briefings on Cluster Lead Agency responsibilities and accountability.

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4. Cluster staffing minimum requirements and costs to be mapped by each WHO Country Office in order to advocate for and secure more sustainable funding with support from Regional Offices and the Global Health Cluster Unit.

5. Document best practice on alternative coordination mechanisms, including resource requirements and clarification of NGO shared leadership role.

6. Accelerate the roll-out and systematic use of Information Management tools and capacity-building support at country level and explore use of advanced technology to improve quality and timeliness of health cluster reporting.

7. Provide guidance on priority policy and operational issues including activity-based costing;

cash-based programming; cluster transition and de-activation.

8. Promote predicable inter-cluster collaboration and response at country level through development of global level pre-agreements with selected Cluster Lead Agencies.

9. All clusters to put preparedness plans in place by end of 2015.

10. Improve the quality of cluster response through review and promotion of core indicators, technical standards, systematic application of the cluster performance monitoring tool and guidance on the monitoring and evaluation framework for strategic response plans.

11. Develop an online ‘community of practice’ to encourage learning and innovation and enhance communication and support to Health Cluster Coordinators.

12. Request WHO to rapidly improve systems, policies and processes for enabling functions including recruitment, finance, administration and procurement to ensure they are fit -for-purpose for emergencies.

Detailed recommendations and allocated responsibilities can be found throughout the report. The Global Health Cluster is committed to take forward these recommendations in collaboration with its partners. Follow up actions are expected to further strengthen cluster capacity and the quality of cluster response. The Global Health Cluster Unit would like to thank all the participants for their valued contribution to the discussion, as well as the WHO Global Conference and Training Centre that organized the event.

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INTRODUCTION The 2015 Health Cluster Forum is the third such event to be held since their inception in 2010. The last Forum was held in June 2013. It remains the only opportunity for all Health Cluster Coordinators (HCCs) to collectively share their technical and operational challenges, good practice and express support needs in an enabling environment with colleagues from WHO Regional Offices, Headquarters (HQ) and some Global Health Cluster (GHC) partners. Information is available at http://www.who.int/hac/global_health_cluster/about/forum/en/. Recommended to be an annual event, plans to host the 2014 Forum were postponed twice due to capacity issues arising from unprecedented levels of HQ staff deployment to the Ebola response and other emerging L3 crises, most notably Iraq. A commitment was made by the GHC Unit to host the Forum by the end of March 2015, allowing more time to secure resources and consult with HCCs on the content. Based on their feedback and recommendations from 2013, the Forum format was extended to 5 days – 3 days for thematic presentations and discussion, followed by two days training on ‘The role of Health Cluster Coordinators on Plans, Programmes and Strategies and Resource Mobilization’. Feedback on the support provided to HCCs by the three levels of WHO was obtained through voluntary participation in an online survey, focus group discussions and one-to-one interviews. Daily evaluations were conducted and reviewed by the organizers at the end of each day and relevant adjustments made to the agenda and overall approach. PARTICIPANTS In total, 33 participants joined the Forum as outlined below and in Annex 1, including:

18 Health Cluster Coordinators and team members representing 23 Co untry Health Clusters/Sectors (8 AFRO, 7 EMRO, 1 EURO, 1 SEARO, 1WPRO)

12 WHO Headquarter representatives

1 WHO Regional Office representative (AMRO/PAHO) 1 GHC Strategic Advisory Group (SAG) member (Helpage International)

1 NGO Consortium surge staff member (Save the Children UK) This is a 31% reduction compared to participant numbers in the 2013 Forum. Underlying reasons for the reduced participation include overriding work priorities such as major donor meetings (e.g. Kuwait donor conference; cluster response scale-up; Ebola response); non-availability due to annual leave and staff vacancies (latter affected co-lead engagement); travel restrictions due to meeting overload and increased security restrictions by some partner agencies arising from the Tunis Museum attack which occurred 4 days before the Forum. Participants felt the limited representation from WHO Regional Offices, NGO co-leads and GHC SAG affected the scope of discussions and that broader engagement should be secured for the next Forum. Among the Health Cluster Coordinators, only 1 was dedicated to that role, the others ‘double-hatting’ as HCC and WHO Emergency Health Action (EHA) focal point. Some even triple and quadruple hat to cover multiple roles. This signifies little/no change in working arrangements since 2013 despite the recommendation to reduce double-hatting, particularly in G3 crises. It is also worth noting that only 8 (42%) of the HCCs participated in the 2013 Forum, highlighting the level of staff turnover and the need to recruit, train and retain sufficient skilled personnel for this challenging position.

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SUMMARY OF THE SESSIONS DAYS 1-3: HEALTH CLUSTER COORDINATION THROUGHOUT THE HUMANITARIN PROGRAMME CYCLE: TOWARDS BETTER ACCOUNTABILITY

DAY 1

Opening Remarks The forum was opened by Linda Doull (GHC Coordinator), highlighting the changing humanitarian context and introducing the GHC team, which has expanded since the last forum. In his welcome note, Dr Rick Brennan (Director, WHO Emergency Risk Management and Humanitarian Response - ERM) reiterated WHO HQ commitment to support HCCs fulfil their role at a time of rapidly increasing health need arising from the current five G3 emergencies compared to only one during the last forum. He acknowledged the humanitarian sector is overstretched as never before and that the unprecedented demands of the Ebola crises has led to a change in the way WHO will respond to future emergencies. The Executive Board in its special session made it clear that the organization needs to review its structure and operational systems, and a number of reforms are currently underway to ensure WHO more effectively responds to future emergencies. This includes changes to the Emergency Response Framework. Dr Brennan reinforced the inconsistent quality of health cluster response and the need to more consistently promote Sphere standards and technical best practice. Finally, he acknowledged that health cluster progress was less than desired since the previous forum. However, recently added capacity in the GHC Unit means HQ is now in a better position to support country health clusters by addressing the recommendations made in 2013 including the planned 2-day training on project management and resource mobilization and the drafting of a Health Cluster Professional Development Strategy. Presentations and background documents are available at this Dropbox link: https://www.dropbox.com/sh/jgxrpokni7eprwf/AAAaRviZ5Pyq4qbtHaeNofqAa?dl=0. Module 1: What’s new at the global level? (Chaired by Dr Rick Brennan) The Global Health Emergency Preparedness and Response Dr Michelle Gayer (Director a.i., ERM) updated participants on the Executive Board Special Session1 held in January 2015, to discuss the Ebola response and how WHO can reform itself to better respond to future emergencies. The resulting Resolution EBSS3.R1 commits the organisation to reform rather than the suggestion to establish a new organisation for health emergencies. The Resolution includes aspects of leadership and coordination; organisational systems and processes; HR capacity and funding. The Ebola response has highlighted that available technical expertise was insufficient and that the ERF was essential to establish the coordination, logistics and management required for an all hazards approach. The ERF is being revised to ensure all systems and procedures are in place. Strong detection and surveillance mechanisms will remain key priorities to mitigate similar emergencies.

1 Ebola: ending the current outbreak, strengthening global preparedness and ensuring WHO’s capacity to prepare for and respond to future large-scale outbreaks and emergencies with health consequences.

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Notably, the resolution recognises the GHC as a key coordination mechanism through which WHO can respond to health emergencies. This is significant given that the GHC was not officially recognised by WHO until 2012 when the resolution WHA 65.20 was adopted, thereby fully recognising WHO as Cluster Lead Agency (CLA). The resolution also recommends that the 4 WHO hosted networks (GHC, Foreign Medical Teams - FMTs, Global Outbreak Alert and Response Network - GOARN and Standby partners) expand, deepen and more effectively align their engagement. Plenary discussion focused on some of the challenges experienced at country and regional level resulting from the current dichotomy in approach between outbreak and humanitarian response, whilst some regions (SEARO, AFRO) indicated they had already taken steps to harmonise their structures to support an all hazards approach. The scope and timeframe for wider organisational reform of emergency work will become more apparent following the 68th World Health Assembly in May 2015. The Global Health Cluster priorities for 2015 Since the last forum, Linda Doull informed that the GHC has expanded from a one-person Secretariat to a Unit with an (interim) team comprising a Coordinator, two Technical Officers and one Secretariat role. Since January 2015, a Strategic Advisory Group (SAG) has been activated t o strengthen governance and oversight of the GHC. The role of the Global Health Cluster Unit (GHCU) is to provide global oversight to Country Health Clusters (CHCs) (24 during the Forum), supporting them to implement quality programmes through coordination and technical support, capacity building and advocacy activities. The current GHC Strategic Framework for 2014-2015 was developed from recommendations by 2013 Health Cluster Forum and subsequent strategy workshop. The 5 Strategic Priorities remain as relevant in 2015 given the increase in active health clusters and demands made on cluster coordination teams. Linda Doull provided a progress report against each strategic priority as outlined below. SP1: Strengthen and expand the global capacity for effective humanitarian health action

A GHC partner capacity survey will launch in April, the results of which will inform recruitment of new cluster partners needed to address technical and operational gaps. Results will be presented at June GHC Partner Meeting.

The ECHO funded NGO Consortium hosted by Save the Children, will recommence in April providing 11 dedicated surge staff for the GHC to fill key cluster functions over the next 2 years.

SP2: Strengthen technical and operational support for country health clusters and coordinators

A fully updated Health Cluster Coordination training is being planned for September 2015.

2-day training on project management and resource mobilisation included in this forum. GHC will conduct focussed support missions where required e.g. to support the CPM exercise.

SP3: Improve the standardisation, quality and timeliness of humanitarian health information

PRIME portal has been launched providing greater access to and support for a range of standard information management tools. All HCCs should sign up and utilise the tools.

SP4: Address strategic and technical gaps

Health Cluster Guide is being revised to support HCCs in their work. SP5: Enhance the advocacy role of the GHC.

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An Advocacy Task Team has been created, composed of WHO staff and partners. HCCs are encouraged to share advocacy issues which are relevant to them via the survey being launched during the forum.

In addition, a new GHC multi-year strategy will be developed in 2015 based on a review of current context and performance, with HCCs being consulted throughout the process. Participants were largely positive about the changes occurring with the GHC and the plans for country health cluster support but expressed the need for the pace of change to be accelerated, especially related to capacity building of regional and local actors, the priority being training national staff in the cluster approach particularly at sub-national level. Update on the Global Inter-Agency processes Dr Ahmed Zouiten (GHC) presented the Humanitarian Programme Cycle (HPC), which was being rolled out at the time of the previous Forum in 2013. He highlighted each step of the cycle and the role of the health cluster in each, in particular coordination and information management which are essential enablers of the HPC. Given the importance of the HPC process and HCC requests to discuss how it impacts on their work, it was decided to frame the 2015 Forum around each step. Presentation of the new WHO Information Management products Mr Samuel Petragallo (Intelligence, Information and Monitoring Team, ERM - IMM) introduced the PRIME platform, the aim of which is to facilitate information management in countries and make information in emergencies more available, predictable and transparent for health clusters, WHO and partners. He described the suite of tools available via PRIME2 and plans to roll these out across countries and clusters to address the current challenge of unsystematic data collection, which hinders comparable analysis. Specific tools were presented in more detail throughout the Forum as their use pertained to a particular step of the HPC. The importance of engaging with this Information Management (IM) platform and tools was highlighted, particularly the added value it offers in being able to provide a global overview and analysis of health cluster activity and impact. Such information is in high demand by donors and fundraisers to more effectively advocate for and inform investments in health clusters.

Recommendations from Module 1: For WHO and the GHC

Important to clarify roles and responsibilities between departments dealing with emergencies and disease outbreaks across the organization.

Clarify and align the roles and responsibilities of GHC, FMTs, GOARN and Standby partners. GHC to increase capacity-building support in emergency response and cluster coordination for

regional and country actors including WHO Country Offices (WCOs).

GHC to increase investment in training national staff in the cluster approach, particularly at sub-national level.

HR, finance and administration processes should be improved to enable rapid deployment of staff into core health cluster functions.

2 MEASURES (Attacks on Health Care), Cluster Description, Cluster Mapping, Cluster Performance Monitoring, Grading Monitoring, ERF Monitoring, HeRAMS, OSCAR (Online Collaborative Situation Analysis and Reporting), SitReps.

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Module 2: Health Cluster/Sector coordination in recent emergencies (Chaired by Linda Doull) The Inter Agency Standing Committee (IASC) Cluster Coordination Reference Module acknowledges there can be no ‘one-size fits all’ approach to cluster coordination due to the differing contexts in which emergencies occur and clusters activated. This session highlighted the variety of coordination models currently being implemented across a range of contexts to identify what works, challenges faced and possible solutions. Health Cluster coordination models at national level Presentations from Iraq, Liberia, Sudan and Myanmar served to highlight a number of important issues which enable or constrain cluster coordination at national level. The key points raised included:

Importance of the 3Ws in Iraq to highlight partners’ capacity and the challenges of accessing ‘hard to reach’ populations in highly insecure parts of the country. Actor mapping identified both the proliferation of and increasing reliance of national NGOs to deliver health services in these areas. It also highlighted challenges in registering and vetting partners; assuring consistency in the content and quality of services provided and how to strengthen capacity where gaps existed. Plenary discussion suggested lessons could be learned from Syria where WHO is supporting a significant number of local partners to undertake surveillance and deliver services in hard-to-reach areas.

Coordination ‘soup’ in Liberia: The Ebola outbreak response resulted in a number of different coordination structures being created whilst the health cluster was not originally recognised by key actors. UNMEER was established as a ‘command and control’ style of coordination and was ‘not minded’ to adopt the cluster approach – the reasons why remain unclear - was it because WHO lacked capacity? This restricted cluster mandate impacted on partner engagement, communication and the ability to secure resources to undertake core functions such as information management. Early differences in approach to the Ebola crisis (outbreak control rather than humanitarian action) are considered to have slowed the overall response. Clarifying emergency management response mechanisms for all hazards is essential. The revised Emergency Response Framework (ERF) seeks to do this including how the cluster aligns when activated. Closer collaboration between WHO ERM and Health Security (HSE) must be prioritised. As the Ebola response evolves, and UNMEER disbands, the cluster approach is now considered to be more relevant in supporting early recovery and revitalisation of essential health services. Plenary discussion focused on the need to clarify the role of the cluster in future similar crises and for stronger engagement by the GHC Unit.

Protracted crisis in Sudan: A long-established and well-structured cluster, it epitomises the challenges faced in many protracted crises, namely how to mobilise sustained resources to continue activities, in the face of increased health needs due to conflict and outbreaks and reduced humanitarian space. Shared leadership with NGOs has been effective but inconsistent due to funding gaps resulting in frequent double-hatting, especially at sub-national level. Solutions proposed included engaging new actors (national NGOs) to increase service delivery and coordination capacities and engage non-traditional donors (e.g. Arab states) to secure longer-term funding support.

Myanmar: Engaging national authorities has always proved challenging in this complex political context. In March 2015, the Ministry of Health (MOH) finally approved the health cluster, two years after it was initially proposed to coordinate health action in Rakhine. This delay resulted

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from several factors including political sensitivities; the cluster being activated against the recommendation of the Ministry of Health (MoH) which impacted on access to the affected population; difficult relations with previous health cluster partners and a prolonged leadership gap within the WHO Country Office leading to a trust deficit with government, partners and donors. Renewed, visible WHO leadership has been critical in securing cluster approval, involving regular contact with government demonstrating the added value of the cluster approach. The main lesson learned is that cluster activation is not a simple linear process - flexible and solution orientated engagement with national authorities is essential.

Many participants felt that weak WHO cluster leadership at country level stems from WHO Representatives (WRs) not fully understanding their role and responsibilities as Cluster Lead Agency, and that ERM/GHC should more effectively brief them and increase their engagement in cluster related dialogue and decisions. Where WRs are actively engaged in their CLA role, the health cluster response and partner engagement strongly benefitted. The WR Ukraine (currently double-hatting as HCC) agreed with the need for strong demonstrated leadership by WHO and engagement with national authorities. However, she also queried how to effectively respond in conflict affected, opposition-held areas where perceptions of WHO being ‘on the side’ of the MoH, impacts negatively on collaboration, hindering sub-national cluster activity. Hiring dedicated personnel for cluster coordination (including partner co-leads) should be considered in this context to promote impartiality. Participants stated that despite, clear IASC guidance on cluster activation, this ‘perfect model’ is not always feasible and a flexible approach to cluster activation adapted to the local context is needed. Reference was made to the IASC guidance which states that if there is a coordination gap, a cluster can be activated without formal IASC approval but with the support of the government (MoH). Discussion ensued on the implications this has for the potential level of resources required by WHO to support both IASC and non-IASC activated clusters and that this should be prioritised in alignment with the ERF grading system. Inter-cluster coordination was identified as an area for improvement, with greater assertion from the health cluster at all levels on how health should be prioritised within other cluster response plans. This could be facilitated in part through global level pre-agreements or statements of intent related to particular response scenarios such as cholera and drought. Health Sector coordination in challenging contexts; alternative coordination solutions: Cluster-like arrangements Presentations from southern Turkey and Malawi introduced health cluster coordination in contexts where alternative coordination solutions where considered necessary including ‘cluster -like’ arrangements. Key points raised are outlined below.

Southern Turkey: In the absence of the UN presence early on in the Syria crisis, the NGO Forum established a Health Sector Working Group (HSWG) 2013 which provided an excellent opportunity to serve coordination needs in the absence of a formally activated cluster. The IASC formally activated the cluster in February 2015 following Resolution 2191. Throughout this process, Syrian NGOs strongly advocated for engagement in strategy development rather than being regarded as merely implementers. Within the HSWG, this raised challenges related to partner inclusion, vetting and impartiality, whilst acknowledging the added value of their in -country knowledge compared to most INGOs. Additional challenges included capacity building for both national and international NGOs respectively to implement according to sector

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standards and to fulfil coordination functions usually undertaken by UN agencies. Actor mapping and gap analysis using 4Ws and HeRAMS have also been complex exercises due to the need to respect anonymity in a challenging security environment. The subsequent adoption of the Whole of Syria (WOS) approach provides an opportunity to build on the NGO led HSWG efforts to reach the Syrian population cross-border and cross-line, and gain a more holistic view of needs and gaps. INGO co-leadership at all levels of the WOS approach remains a critical component to ensure and support national partner inclusion and development.

Malawi flood response presents a case of a country with little experience of emergency response, and hence limited understanding of the ERF and the cluster approach. A joint Health and Nutrition cluster was activated by the Malawian government (not the IASC) as part of its Disaster Management Response Plan and was led by MOH with WHO acting as co-lead. In this particular context, WHO’s role appeared largely administrative (e.g. convening meetings, developing sitreps, bulletins) rather than playing a more active role ensuring understanding of emergency/ cluster structures by MOH and WHO colleagues in-country, particularly at sub-national level.

Participants agreed that alternative coordination mechanisms / ‘cluster-like’ models can be very beneficial and should be considered and supported where appropriate. The cluster principles (including its six core functions and associated tools) can be applicable in non-IASC activated cluster settings. However, there must be clarification of the roles of different agencies. Where the MOH leads the cluster and WHO is co-lead, WHO can provide technical support/ secretariat roles, however respective roles should be clearly pre-agreed with the MoH. In addition, the GHC need to be clear on its role in supporting non-IASC activated clusters and where there is no Humanitarian Coordinator. PRIME application: using a platform for Cluster Description and Mapping Mr Samuel Petragallo demonstrated the Cluster Description and Cluster Mapping tools available through the PRIME platform. These tools enable the Health Cluster at all levels to track each cluster in respect of its status (active or not, formal or cluster-like); structure at national and sub-national level, resources (staffing, funding) and response progress (bulletins, sitreps). Through more systematic mapping, improvements in cluster support plans and resourcing can be made. All HCCs are encouraged to populate and regularly update their respective cluster descriptions.

Recommendations from Module 2: For WHO and the GHC Improve WR briefings on the cluster approach and explore opportunities for more regular

dialogue with WRs and Regional Offices.

Clarify GHC support to (non-IASC) cluster-like contexts. Further clarify NGO co-leadership role especially where WHO cannot be the lead agency.

Clarify rationale for alternative coordination mechanisms and provide 2-4 examples along with resource requirements.

For Country Health Clusters

Regularly map cluster status and produce quarterly global dashboard.

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Module 3: Informing strategic decision-making in the humanitarian response (Chaired by Dr Ciro

Ugarte)

Dr Ciro Ugarte (Director, Emergency Preparedness and Disaster Relief, AMRO) stressed information management as one of the critical functions for WHO’s response in emergencies as defined by ERF guidance. It is one of the Cluster’s six core functions, and a vital element of the HPC. Providing an evidence-based, effective and efficient health response cannot be achieved without heavy reliance on a solid information management system throughout the phases of the HPC. Needs assessments in challenging contexts Presentations from Iraq (rapidly evolving context), Guinea (Ebola affected country) and the Philippines (sudden onset disaster) were used to summarise different experiences of conducting needs assessments in challenging contexts.

Iraq provides valuable lessons learned from the recent Level 3 emergency. The original Humanitarian Needs Overview was launched when approximately 400,000 people were displaced in different governorates. This number increased to 1.8 million IDPs before the Humanitarian Needs Overview exercise was completed. To continue to provide evidence-based programming, the Health Cluster established a network of focal points (MOH staff supported to perform continued health assessments) in all the governorates. The terms of reference of each focal point include: i) immediate incident reports; ii) EWARN surveillance reports and iii) weekly assessment reports. The network has helped WHO and the Health Cluster to adjust the health response according to the rapidly evolving needs, whilst contingency plans were based on worst case scenarios.

Guinea outlined the difficulties encountered by the health cluster due to the overwhelming and polarising demands of the Ebola outbreak response, which resulted in extremely weakened primary health care services. Investing cluster resources in Ebola, reduced oversight of the other primary health care needs of the population. Resources to support needs assessment could have identified gaps in essential services at an earlier stage.

The Philippines highlighted challenges encountered at national and sub-national levels

implementing Initial Rapid Assessments. The presenter emphasized the need for simplified, ready-to-use assessment tools; the need to train assessment personnel as a matter of preparedness, harmonizing data collection and analysis as well as standard indicators to be collected. These prior actions would have avoided the delays experienced.

Use of IM tools for producing evidence-based needs assessments The ERM Intelligence, Information and Monitoring (IIM) team presented the different tools and methodologies recommended for use in different emergencies. MIRA: is for multi-cluster rapid assessment. Now 2 years old, its use is most valuable in acute onset crises, and has limited use in protracted crises. MIRA tools are currently being updated but unlike the first version, the second draft is not based on the Humanitarian Emergency Settings Perceived Needs Scale (HESPER). The HESPER scale, developed jointly by WHO and Kings College London, is the only tool that has undergone a scientific evaluation. It measures health needs as perceived by the population. Most participants were not familiar with HESPER.

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HeRAMS: Health Resource Availability Mapping System is used to assess the availability of healthcare services in a given area (district, region, country). It is a facility-based assessment focusing on functioning of a health facility and the availability of services. It does not assess service usage and cannot give an idea of the disease burden. HeRAMS exercises can be a lengthy process, but different strategies are being tested to decrease the data collection time including the use of reporting devices (e.g. tablets, smart phones). The IIM team supported Central African Republic (CAR) to investigate 800 health facilities following the L3 declaration. HeRAMS outputs including automatic reporting and interactive maps (such as 4Ws) has greatly assisted decision-making, supported resource mobilization, helped monitor the impact of the crisis on health structures, informed the development of the health sector transition plan and health staff deployment to the facilities. HeRAMS applications at country level has proved that the tool is more effective when used pre- crisis as a preparedness tool to provide baseline data. This baseline can be quickly updated at the earliest stage possible in the emergency response phase. Iraq and Ukraine have successfully used tablet devices for instant data collection – these can be an excellent tool, and warrant further research for use in other contexts. It was noted that their use can be influenced by connectivity and security context. Lessons Learned

Information Management is at the centre of effective health action. In order to fulfil this core function, every health cluster team should have dedicated Information Management capacity.

The health cluster team should invest in strengthening needs assessment capacity by: i) providing in-country capacity-building to health cluster partners ii) promote greater standardization of needs assessment tools and methodologies amongst cluster partners including the national authorities; iii) engaging in secondary data analysis as early as possible in the assessment process.

The health cluster should take into account the geo-political situation, and allow more flexibility to conduct more assessment as the emergency evolves.

The use of modern technologies including tablets and smart phones can reduce assessment timeframes. Whenever possible, the cluster should explore innovative ways to collect, analyse and disseminate data.

Recommendations from Module 3: For WHO HQ and the GHC

Finalize the cluster in a box with all the available tools, templates and examples of good practice and quality products.

Include IM and IMOs in the Health Cluster Coordination training. Define standard indicators to be monitored during the different phases of the emergency.

Finalize the HESPER scale tool and make it accessible through PRIME. For Country Health Clusters

Ensure that every health cluster team includes an IM Officer.

Ensure full partner engagement in joint needs assessment exercises. All health clusters should regularly update their 3W mapping exercise.

All health clusters should implement HeRAMS as baseline exercise at their earliest convenience. IIM team is ready to support.

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Module 4: Strategic response planning (Chaired by Dr Michelle Gayer) Strategic response planning development in new and ongoing emergencies Dr Michelle Gayer opened the session by highlighting that the strategic response plan (SRP) is designed to support country-based decision-makers. It communicates the shared vision or strategy to respond to the assessed needs, and serves as the basis for implementing and monitoring the collective response. However, SRPs can be a cumbersome process, and may not always be prepared or utilised effectively. Country experiences were presented from South Sudan, Mali, Myanmar and Ukraine as follows:

SRP development: from humanitarian needs to strategic priorities in South Sudan: the HCC described the steps for developing the 2015 SRP. The process used the results of the Humanitarian Needs Overview, and was facilitated by OCHA with active participation of the government. The overarching strategic objectives were decided in the inter-cluster workshop while the Health Cluster response plans were set by the Strategic Advisory Group who worked together to agree on key strategic priorities and activities, geographical priority setting, key indicators to be monitored, and three major areas of the response identified with a strategic objectives to address each.

Using the 3Ws to perform a gap-analysis and avoid duplication in Mali: the HCC described how the 3W matrix and analysis was used to support coordination decisions at country level. It is regularly used to identify gaps in terms of staffing, infrastructure and health services including medical technologies, medicines and vaccines. The HCC emphasized that the 3W matrix should be updated regularly.

SRP development in Myanmar: a model for activity based costing: Activity based costing is being increasingly required in the SRPs, having been introduced to avoid the disparity between UN and NGO partners’ costs and to enable more reliable and competitive costing. However, activity based costing within the health sector is still challenging as the cost of different health services can vary greatly. In Myanmar, a retroactive case-study was conducted to inform the average cost per activity; however, great disparities between national NGOs, INGOs and UN persist. It was noted that currently there is no standard, robust methodology and people are still unclear how to go about the process. Similar experiences in Ukraine and Yemen show that it is very difficult to calculate cost per beneficiary in the health sector (costs are different for IDPs vs host population, and family planning vs emergency C-section). Linda Doull explained that the GHCU and ERM/PPE are in dialogue with OCHA on these concerns which most other clusters share.

Developing strategic objectives and monitoring frameworks in Ukraine: the development of the strategic objectives in Ukraine started by thorough gap analysis from which clear objectives were developed to address the gaps. The WR/HCC stressed the importance of using language which can be understood by all (non-technical) stakeholders. Activities and higher level indicators were developed. Each of the 21 activities planned were based on the health SPHERE standards.

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Role of the different cluster partners in the SRP process Presentations from the Philippines, Democratic Republic of Congo and Southern Turkey highlighted the different role cluster partners fulfil during the SRP process, depending upon the prevailing humanitarian context and architecture. In the Philippines, the government recently adapted the cluster system to develop one system covering WASH, health, nutrition and mental health and psychosocial support (MHPSS). Another system also exists under the government’s rehabilitation and recovery department, where health falls under the social services sector. SRP inputs had to be adapted accordingly. Inter-cluster coordination was stressed as a priority, ensuring that synergies are explored to reach overall joined inter-cluster objectives, as well as cluster specific objectives. For example, in the Democratic Republic of Congo, the health cluster also includes nutrition partners and UNHCR to ensure that health needs of refugees and protection issues are covered. In Ukraine, the health cluster engages particularly with nutrition, protection, food (e.g. for hospitals), shelter (e.g. heating tents for winter), WASH, early recovery and logistics. Sub-national coordination is regarded as key component of health cluster coordination, but can be challenging. In particular, weak communication between national and field level coordinators and in many instances insufficient human resources to cover sub-national level coordination function at the required level. Southern Turkey demonstrated that NGO partners can be an excellent opportunity to support health cluster coordination, in the absence of UN agencies. As the UN was not able to be present in Southern Turkey until after resolution 12/65 was passed in mid-2014, the NGO Forum (chaired by Save the Children) filled the coordination gap. NGO-led coordination resulted in NGO partners becoming more engaged and led to the ‘cluster’ being more programme-oriented and funding being more flexible. Two important challenges included how to most effectively engage national NGOs in SRP development and responsibility for provider of last resort should it arise. A recurrent theme arising from each example was the need to promote the use of reliable health indicators (e.g. morbidity/mortality rates or percentage of functional health facilities) at health cluster level as the inter-cluster process focuses on total number of beneficiaries reached. Advocacy within the inter-cluster coordination as well as among donors should be made to enable the prioritization of health indicators where possible. Lessons learned

The SRP development process is an extremely important phase of the HPC. The health cluster should engage early to ensure that life-saving health needs are appropriately prioritized in the strategic plan.

Evidence-based programming is paramount for an effective health response. The health cluster should use the Humanitarian Needs Overview and the needs assessment to inform the development of the SRP.

Involving all the health cluster stakeholders in the assessment process and strategic planning ensures greater partner engagement in the response.

Defining SMART indicators is essential to a quality health response.

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Recommendations from Module 4: For WHO HQ and the GHC

The GHC should provide guidance on activity based costing to assist country clusters in this exercise.

The GHC should provide an example list of strategic objectives and key activities to guide SRP development.

GHC to share the list of SMART health indicators recommended for SRP development. Strengthen health cluster teams in-country during the SRP planning process to ensure health is

prominently addressed and work-load manageable.

Include strategic planning skills in the Health Cluster Coordination training. The GHC should further explore the shared leadership model – develop a generic TOR and

disseminate to all HCCs. Include in cluster-in-a-box. For Country Health Clusters

HCCs should engage with Inter-Cluster Coordination fora at the earliest opportunity to ensure health activities are prioritized and synergies with other clusters are developed.

Ensure that sub-national hubs for coordination are adequately staffed.

Engage government as well as other stakeholders throughout the planning exercise. Create health cluster Strategic Advisory Groups to ensure representation of key stakeholders in

the planning process.

Emphasize the use of monitoring frameworks to regularly collect data on agreed indicators.

DAY 2

Planning Health Cluster Coordination Teams The day opened with a brief presentation from Linda Doull on an ‘Ideal Cluster Coordination Team’ proposed by the GHC Unit following requests made by HCCs and cluster partners during the GHC meeting in December 2014. The matrix (see annex 3) suggests the minimum number of core cluster positions required for each graded emergency as defined by the WHOs Emergency Response Framework. Whilst there is no one-size-fits-all cluster coordination team structure, this matrix can be a useful tool to assist planning and budgeting cluster staffing requirements. Dialogue between donors and CLAs indicates their willingness to support cluster coordination costs, but critical information on coordination needs and costs has never been clearly articulated by any cluster. By using this simple matrix each country cluster could estimate their coordination needs and costs, which can be used to inform donor discussions at all levels. The GHC is committed to promote the need for sustainable cluster coordination funding – particularly in protracted crises. Through improved planning, short term surge will also be more effectively deployed, by reducing gap-filling.

Recommendations for Country Health Clusters

HCCs to discuss cluster staffing requirements with their WRs and to plan and budget for these accordingly. These requirements should also be shared with GHC at HQ-level for advocacy purposes.

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Module 5: Implementing and monitoring the response (Chaired by Dr Michelle Gayer) Implementing the Cluster Response Plans Presentations from Ukraine and Yemen raised the following key points:

Cluster priorities should not only focus on immediate emergency needs, but also the longer term health system strengthening needs, as clearly evidenced in Ukraine.

Robust information management is central to implementing the response and IMOs should be prioritised where possible. In Ukraine, the IMO has established tablet systems to gather real-time data on services provided and people reached. This enables reports to be instantly generated (the system updates every hour) improving targeting and delivery of services in a highly volatile security context. There was consensus among participants that the use of tablets in this way should be replicated across clusters where feasible.

Implementation plans must be put in place to reach marginalised populations. In Ukraine, Roma doctors have been hired to ensure that the marginalised Roma populations are reached.

Inter-cluster collaboration is critical, most notably with nutrition, food, WASH and logistics clusters. Collaboration with the nutrition cluster in Yemen has been effective due to inclusion of nutrition activities in health sector plans. It was acknowledged that strong leadership from WHO in-country and at global level is required to champion effective inter-cluster/agency collaboration.

It was agreed that the GHC should explore more concrete options to ensure other clusters

support health outcomes, such as having pre-agreed ‘Statements of Intent’ at global level to

facilitate rapid convening of inter-cluster programming.

HCCs were reminded that WHO has an MOU with World Food Programme for logistic and

communication support in all crises, which should facilitate inter-cluster collaboration.

Recording achieved results against the objectives set out in the SRP The discussion focussed on how to effectively document the results of cluster activity, with presentations from Iraq and South Sudan. A range of cluster bulletins and sitreps are used to demonstrate the achievements of all cluster partners. South Sudan was commended for being one of the few countries which produces regular updates through a range of different products, thanks to partners working together. There were queries around the number of products being produced by the cluster, and concern about duplication. It was advised to rationalise the number of communication products, minimum requirements being a sitrep early in the crisis, converting into a health cluster bulletin as the crisis develops. It was agreed that an IMO is critical in enabling the cluster to produce quality documents. Challenges exist regarding the development of cluster reports:

Some indicators are in absolute numbers, rather than percentages, which is misleading to the meaning and progress of the indicator.

Security issues can prevent partners sharing information.

Always challenging to receive timely and complete information from partners every week. Guidelines and formats have been developed to facilitate collection of partner data.

Clusters are often asked to complete too many similar, reports to show progress. Discussion focused on the how to measure programme quality through effective use of indicators. There was consensus that the number of indicators should be rationalised, data validated where possible and that the use of rates rather than absolute numbers should be encouraged. Clusters

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often lack technical guidance on how best to develop and monitor indicators. Where possible, the same indicators should be used in the SRP and in donor reports. Ideally the health cluster should also share all partner information with the government, but this should not replace the need for partners to share their own information with the government. Validation of partner data remains a challenge, especially as the health cluster has no supervisory role over its partners. In South Sudan, a team of volunteers exists within the cluster to pay visits to project sites to validate the information of partners. However, poor communications and insecurity can hamper the efficacy of this approach. Discussion on disaggregation of data beyond two age groups (under 5 and above 5) was held. The majority felt these groups were sufficient to summarise priority information, such as outbreak surveillance, but further disaggregation is needed for more specific programme design. However, the majority view suggested age disaggregation as challenging due to the MoH templates. The GHC coordinator highlighted that diversity issues such integrating age into SRP activities were always identified as a weakness in cluster performance monitoring reports. This is unlikely to improve unless relevant data informs activities.

Recommendations from Module 5: For WHO HQ and GHC Implementing the health cluster response plan:

Global level pre-agreements should be developed to promote predictable inter-cluster collaboration at country level.

Lessons learned on use of tablet devices in Ukraine and Iraq should be documented and their use be made routine (where feasible).

Recording achieved results: Technical guidance on monitoring and evaluation be provided to health clusters

Minimum reporting requirements and information products to be defined Health indicators reviewed and core data set agreed.

Prioritise IMO within Health Cluster core team.

Module 6: Monitoring the health cluster performance (Chaired by Dr Ahmed Zouiten)

Monitoring health cluster performance in 2015 Since the 2013 Forum, uptake of the Cluster Coordination Performance Monitoring tool (CPMt) has declined – 10 clusters undertook the exercise in 2013, compared to only 6 clusters in 2014 (30% of active health clusters). Whilst a recent review by OCHA shows that this rate is higher than any other cluster, the fact remains that systematic monitoring is still not being prioritised, despite the increased emphasis on the need to assess performance and demonstrate accountability. Participants were informed that the CPM tool is now available through the PRIME platform along with remote support from the ERM IIM team throughout the CPM exercise. It is hoped that more user-friendly access and automated analysis will encourage uptake. Pakistan, Sudan and Iraq gave presentations on their most recent CPM experiences. Each felt the process was useful to assess core functions, with high levels of partner engagement. Clusters which have performed successive CPMs (Pakistan and Sudan) appear to have improved their performance

19

over time as indicated by increased good and satisfactory responses in most areas. However, areas for improvement flagged across all clusters completing the exercise were addressing diversity is sues within cluster response plans in particular disability, age and HIV; preparedness planning and advocacy. Participants felt diversity issues are often ‘ignored’ as partners leave this work to ‘experts’ rather than learning to more effectively mainstream activities within cluster response plans. Some practical aspects of the CPMt were discussed, including the challenges of roll-out in remote settings with weak IT connectivity. The IIM team confirmed that it is not necessary for all partners to register on PRIME to complete the CPMt. Furthermore, it may not be necessary to conduct the exercise at sub-national level as the tool is less relevant for small coordination processes – this will be considered during the review process. It was also suggested to revise the range of the assessment scales as over time most feedback ends up being green which can encourage complacency. Participants debated whether the CPMt is really a good indicator of cluster performance as it focusses only on the coordination process rather than deliverables and programme quality. This prompted debate on whether the cluster is responsible for the delivery of health standards, or merely a coordination mechanism. The unanimous view was that the health cluster should have oversight of programme quality and actively promote technical standards among partners. Whilst the CPM tool was never designed to monitor deliverables, merely to serve as a trigger for further discussion, there was consensus that the current tool should be reviewed and adapted to include a focus on deliverable and technical standards. This issue has also been flagged by the Global Cluster Coordinator Group (GCCG) for action in 2015. Participants were reminded that the CPM should be carried out 3-6 months after the onset of a new crisis and at least annually thereafter. The current GHC target is for 75% of clusters to complete the exercise by the end of 2015, which means 18 clusters in total. At the time of reporting, Iraq, Mali and Niger have initiated the process, with tentative plans from Sudan, Pakistan, Ukraine, DRC and Myanmar. All clusters were encouraged to confirm their plans with the GHC Unit and IIM team so that necessary direct or indirect support can be organised.

Recommendations from Module 6: For WHO HQ and the GHC

GHC and ERM Policy, Practice and Evaluation (PPE) and IIM teams to review how CPM process could be adapted to address the quality of the cluster response.

GHC to provide guidance on how to integrate cross-cutting issues. For Country Health Clusters

Clusters to plan for the CPM process in 2015 and confirm timeframes to IIM and GHC Unit by the end of April.

Module 7: Enhancing the role of the health cluster in preparedness (Chaired by Dr Rudi Coninx) What is the preparedness role of the health cluster in protracted emergencies? This session aimed to further clarify and confirm the role of clusters in preparedness within the context of renewed global commitments made during the Third UN World Conference on Disaster Risk Reduction held in Sendai in March 2015. Rudi Coninx (Coordinator, ERM Policy, Practice and Evaluation Team - PPE) provided an overview of the conference emphasising the centrality of health

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within the new Sendai Framework for Disaster Risk Reduction 2015-2030 as evidenced by health mentioned 36 times compared to only 3 times in the previous Hyogo Framework. Of the seven global targets, four are related to activities which ERM is supporting: reduce global disaster mortality, reduce damage to critical infrastructure (health facilities), increase the number of countries with disaster risk reduction strategies and increase early warning systems. The IASC Cluster Coordination Reference Module (page 17) clearly states the role of clusters in preparedness at country and global level including the 5 components of the Emergency Response Preparedness Approach. In addition, the HPC Guide recommends that SRPs should be structured to include preparedness/contingency plans relevant to context, to enable effective cluster response. However, despite this guidance, a show-of-hands among participants indicated low rates of preparedness action being implemented across health clusters. The Democratic Republic of Congo presentation highlighted good practice, with detailed contingency plans addressing a wide range of potential threats including military operations, volcanic eruptions and Ebola, and the adaptive operational approaches used to ensure access to essential health services (e.g. RRM). The key message being that all stakeholders must be fully engaged in the process and be tasked with clear roles and responsibilities. Pakistan, Guinea and Niger also commented that preparedness has become a core component of their cluster activities, based on learning from recurring crises and response. All mentioned an annual contingency planning process, the development of which was either led by OCHA or national disaster management agencies, to which the health cluster contributed. There was consensus that preparedness action must be based on good gap analysis, and that HeRAMS can be a very useful preparedness tool, in helping to establish a baseline of health facility functionality. The presentation from Sudan provided a strong example of regular HeRAMS use which ensures that NGOs and MOH supply data from 947 health facilities on a quarterly basis. The quarterly and annual reports generated from these health facility mapping exercises are used to inform and adapt contingency plans. Whilst a further show-of-hands indicted that the majority of HCCs were familiar with HeRAMS, many did not use the tool on a regular basis and several expressed they would like support with implementation and analysis. Linda Doull confirmed that remote and/or in country support could be provided by the IIM team at HQ and the wider GHC IIM Task Team. At the end of the session, participants affirmed the role of clusters in preparedness and agreed that more action was needed to address the current imbalance between recognising the need for contingency planning versus having clear plans in place.

Recommendations from Module 7: For Country Health Clusters

All clusters will develop a preparedness plan, with support from the PPE team and GHC Unit. All clusters will conduct a baseline HeRAMS exercise to inform preparedness plans by the end of

2015. Clusters which have already developed preparedness strategies should share them with HQ for

review by the PPE Team and GHC Unit.

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Module 8: Transitioning of clusters (Chaired by Linda Doull) Cluster deactivation and transition strategies During this Forum, 21 officially activated health clusters and 4 cluster-like mechanisms were coordinating the health response in acute and protracted crises. Created to be time-bound and active only when there are specific gaps in humanitarian response, the general perception is that clusters are typically more easily activated than deactivated. This session aimed to explore some of the factors which enable or hamper cluster transition and de-activation based on recent experience in Haiti and the Philippines. The discussion began by identifying if and where the conversation around de-activation is happening. Ideally this should be at Humanitarian Country Team (HCT) level, with CLAs providing the appropriate analysis as to whether cluster deactivation is a viable option and feeding into any dialogue around this change. However, in the case of Haiti and Philippines, the respective governments appropriately took the lead on these decisions with varying levels of input from the CLA. In Haiti, the MoH and WHO were originally co-leading coordinating the cluster (after some initial reluctance from government to establish the cluster). At the end of 2014, the MoH decided that the WASH and health clusters should be deactivated. The health cluster is now organised within an ‘emergency cell’ at the MoH – currently restricted to cholera response, but will not be activated to lead the response to the next major disaster event. Development partners continue to meet regularly through the Health Sector. In the Philippines, the national cluster was originally activated post-Haiyan (Nov 2013), and later suddenly deactivated in May 2014. A cluster-like approach continued until Feb 2015 with fewer partners and meetings, combining health, MHPSS, WASH and nutrition. Following Typhoon Ruby (Dec 2014), the cluster was only formally activated at provincial level. In Pakistan, whilst the cluster system has been officially deactivated by the government at national level, it remains active in the NW Khyber Pakhtunkhwa Province, with policy and strategy meetings held at health sector meetings in Islamabad. Through experience of multiple crises and strong leadership from the National Disaster Management Agency, the cluster approach has been integrated into sectoral plans and can be activated when required. In comparison, in Somalia, sectors and clusters cover quite different issues, with sectors covering development activity, and clusters covering emergencies, so the model of automatically switching from a sector to a cluster might not be relevant for all contexts. Participants working in protracted crises (e.g. Sudan and DRC) stated it was challenging to deactivate a cluster as the level of need continues to exist, as when the cluster was initially activated. In such cases, early recovery should still be included in cluster response plans. However, it was recognised that the process for assessing the capacity of national agencies to reclaim responsibility and accountability for health cluster actions is not always clear, nor are the specific benchmarks to be met for the transition phase and eventual de-activation.

The discussion revealed the often complex and country specific circumstances which will influence eventual cluster transition and deactivation. The most important being the way in which national authorities are (or are not) involved in the initial activation discussion and subsequent cluster leadership. Another defining factor is the extent to which coordination architecture is reviewed as the crises evolves. Participants indicated that very few of their clusters underwent the Humanitarian

22

Country Team led annual architecture review process recommended by the IASC or that they were poorly performed. Finally, even when clusters are deactivated, as can be seen from the Haiti, Pakistan and Philippines examples, alternative coordination mechanisms continue to exist, as gaps in health capacity persist. How the cluster and/or its principles co-exist in these contexts requires further exploration.

Recommendations from Module 8: For WHO HQ and the GHC

Provide guidance on how to undertake capacity assessment prior to transfer of cluster responsibilities.

GHC/ERM-PPE to provide guidance on methodology for annual reviews.

3-4 good practice examples of cluster transition and deactivation should be documented by the GHC/ERM-PPE to inform policy and practice.

For Country Health Clusters All health clusters should perform their own annual review process to assess whether the

existing structure is fit for purpose and relevant to context (particularly in protracted crises).

DAY 3

Module 9: Supporting the health cluster to perform the cluster functions (Chaired by Rick Brennan) As in previous Forums, the GHCU organized an online quantitative survey using an ordinal scale to gather HCC feedback on the perceived support they received from different levels of the organization over the last few years. The Country Health Cluster Coordinator/Team members were asked to rank the support provided to them on a scale from 1 to 10 in the following areas:

Supporting the cluster to deliver on its core functions - Setting norms, policies and guidelines - Providing technical support throughout the humanitarian program cycle - Proposal review and feedback

Information Management Cluster Performance Monitoring

Communication and advocacy Contingency planning/preparedness for recurrent disasters

Other support from the WHO Country Office Other support from the regional office

What suggestions do you have to improve technical assistance to the health cluster?

The online survey questionnaire received 39 responses, with 25 complete responses representing 64% (n = 25). The results of the survey were as follows: The level of organisational support to country health clusters and HCCs in particular has been a

topic of considerable concern as outlined in the 2013 Forum report.

In general, the scores were quite low for support from WHO HQ, indicating the perception of minimal support to HCCs. Perceived support from country office and regional level was deemed higher

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- Information Management scored 5/10 – stronger in supporting to develop tools than in analysis and reporting.

- Cluster Performance Monitoring support scored 5.5. - Communications and advocacy scored 4.5 for support on sitreps, 6 for support on

advocacy/comms. - Contingency planning and preparedness scored 3.5. - Other support scored 3 – 2.5 for career development, 3.5 for moral support, 5 for

training opportunities. - Support from country office scored 9, and from EHA unit scored 9.

Dr Xavier De Radiguès from the IIM team presented the results and highlighted that the scores are similar to the 2013 survey, albeit a bit lower for regional and HQ. However, he warned against making direct comparisons as the sample size was smaller this year. He observed that it might have been better to perform the survey in advance of the forum with a larger sample of HCCs. Most from country office has increased since last year. In addition to the survey, participants were invited to join informal focus group discussions held over two evenings to provide additional feedback on their particular support needs. Participation was voluntary and the majority of HCCs took up the opportunity. Common themes emerging from the discussions included the lack of resources; frustrations around being double hatted; lack of professional development opportunities; problems with admin, finance and HR systems. Most of these issues are similar to those raised during the 2013 Forum. Whilst participants felt positive about the GHC Unit championing their cause, they indicated the need for accelerated action to address their concerns.

Recommendations from Module 9: GHCU to ensure delivery of currently planned capacity-building /professional development

deliverables.

GHCU to establish a virtual Forum for regular inter-HCC dialogue. GHCU to collaborate with HO/RO/WCO to secure resources in support of minimum cluster

staffing requirements.

Module 10: Strengthening service delivery: a matter of accountability (Chaired by Linda Doull) In 2014, the level of humanitarian need surpassed previous records, with greater numbers of people including refugees and IDPs than at any time since the Second World War, severely challenging the international community response capacity as never before. The complexity and scale of crises has outstripped existing humanitarian response capacities and funding, resulting in significant unmet need, particularly in health as outlined in the 2014 MSF report entitled ‘Where is Everyone?’ which suggests the existing global health emergency workforce is becoming risk averse which leads to unmet needs especially in conflicts and security compromised settings. This session sought to explore possible strategies the GHC partnership should reflect on to increase the global capacity to respond to humanitarian health needs arising from the ever-growing crises around the world, as well as advocating for more adequate resources for the health sector during emergencies. The discussion highlighted the following points:

Health clusters are struggling to fill the gaps in security compromised and hard to reach areas, as health cluster partners are reluctant to take risks. However, the experience from Syria, Iraq and Yemen is showing that strong mapping of partners capacities’ at country-level, as well as

24

remote-control programming and reliance on national NGOs can be an effective way to fill these gaps.

Experiences from recent emergencies indicate that the clusters are facing consistent technical, HR, operational and funding gaps. However there is weak evidence from our programs from which to learn lessons and advocate for support. This evidence is required from country health clusters to enable GHC to advocate for appropriate resources.

Administrative processes within WHO are not always conducive to support rapid deployment and operational response expected from the health cluster.

IM tools should be utilised to help identify operational and technical gaps, and also to identify the availability and capacity of partners to be able to respond in these areas.

HCCs expressed concerns about assuring partners meet minimum standards of quality programming and the difference in standard between national and international partners. HCCs should be able to articulate the minimum standards expected of partners, and if partners are not meeting minimum standards or are conducting detrimental work, the HCC should be in the position to raise this with the partner or escalate it to the Humanitarian Coordinator level.

When the quality of services is an issue, the health cluster should assess the capacity of all partners and provide the appropriate training (e.g. in SPHERE, Minimum Intervention Service Package, Integrated Management of Childhood Illness).

MOH involvement in the cluster remains highly variable. WHO leadership plays an important role in MoH engagement.

MSF’s role in the cluster was discussed with different experiences across clusters – sometimes active, often just observers. They often don’t align with cluster plans and may replicate what is already being done in an area. The GHC should advocate for more consistency in the role of MSF in the cluster at country level

A discussion was held on whether FMTs could start to fill some of the capacity gaps. The FMT coordination mechanism is providing much more scrutiny on which partners can qualify as FMTs, and defining standards for this.

Recommendations from Module 10: For WHO HQ and the GHC

GHC needs to support a country cluster level exercise to provide evidence on operational challenges and gaps, and advocate for relevant support.

GHCU should update and disseminate ‘Guidelines for Emergency Response’ which has links to all documents with key WHO guidelines/standards used in Emergencies.

GHC should map the global health response capacity to identify technical and operational gaps and advocate for resources to strengthen the global health work force.

For Country Health Clusters

HCC should ensure cluster partners are aware of minimum standards. All clusters undertake a partner capacity mapping exercise at country level.

The HCC should educate the NGO partners on the minimum commitments for the cluster engagement, including the role and responsibilities each partner has in contributing to an effective, efficient and accountable health response.

Module 11: Looking forward: a new Global Health Cluster strategy – Chaired by Linda Doull Linda Doull opened the session by informing participants that a new GHC multi-year strategy will be developed and endorsed by the end of 2015. The new strategy will guide GHC’s work from 2016 onwards (for at least two years), and position the Cluster within the evolving global context,

25

measure performance and support resource mobilisation. Dialogue with donors to date suggests a willingness to support cluster activity at all levels, based on a clear and impactful cluster strategy. Donors expect the strategy to be multi-donor funded with continued contributions from WHO as CLA. The strategy will be developed by the GHC Unit and the SAG through a consultation process with key stakeholders. This brainstorming session with HCCs was the first of a number of opportunities for them to inform the strategy. Participants were divided into five groups and asked to conduct a first -level SWOT analysis of the five strategic priorities in the current Strategic Framework (2014-2015) based on their particular cluster experiences. Each group was allocated one strategic priority. Group discussions were wide ranging and summarised below. Strategic Priority 1: Strengthen and expand the global capacity for humanitarian health action The group reaffirmed the importance of the SP1 but suggested a number of revisions to ensure any expansion of global capacity is fit-for-purpose to meet complex needs at country cluster level. This includes investing in stronger leadership capacity at national and sub-national level; improving the knowledge and skills of potential surge staff at all levels within WHO; greater promotion of shared leadership with co-leads from NGOs and MoH at national and sub-national level; greater recognition and inclusion of WHO Regional Offices in cluster action/support; broaden the scope and participation of stakeholders beyond existing ‘traditional partners’ e.g. private sector, development actors. Strategic Priority 2: Strengthen technical and operational support for country health clusters and co-ordinators The group reaffirmed the importance of SP2 but proposed the need to focus efforts on more practical, fundamental priorities including: securing resources to ensure clusters have a minimum standard of staff in post (as per the ‘Ideal Cluster Staffing Matrix) to perform core functions on a sustainable basis; developing a training module to sensitise cluster members on their role and responsibilities; increased frequency of regular joint missions from the GHCU and Regional Offices to country clusters; finalise development of cluster toolbox to properly equip staff to work in an efficient manner. Strategic priority 3: Improve the standardisation, quality and timeliness of humanitarian health information The group reaffirmed the validity of all activities falling under SP3 whilst stressing the need for accelerated action to deliver against GHC work-plan targets. Strengths and weaknesses reflected previous Forum debates on IM including the availability of tools, standards and indicators but the need to tailor these to context and promote uptake and skills among cluster partners; strong IM expertise at HQ but insufficient dedicated staff at country level; persistent lack of uniformity of information management whilst recognising that online tools via PRIME offer potential solutions; over emphasis on data collection whilst information analysis and use to inform programme design is weak. Threats identified included operational challenges such as insecurity hampering data collection; contradictory /inaccurate information leading to lack of trust among stakeholders; lack of funding to sustain key IM positions which undermines the clusters ability to validate and quality assure health information. Despite these challenges, the group identified a number of opportunities including the high demand for information and donor willingness to support action to improve IM; IT innovation making it easier to collect and analyse data in a timely manner (e.g. Ukraine tablets for real-time gap analysis); the cluster provides a platform to promote /support

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harmonisation of data/IM; WHO reform of emergency management, recognition of and investment in IM. Strategic priority 4: Address strategic and technical gaps This group observed that critical gaps in guidance remained including standard global guidance and tools on leadership and coordination in the context of national conflicts; better delineation of needs assessment tools for acute and protracted contexts and an emergency response framework for protracted crises. Whilst the group recognised the challenge of global guidance being adopted by all partners, the advantages of having comparable information are evident and the GHC should more pro-actively advocate with partners to align. The group also felt that the health cluster should differentiate its activity from WHO through separate branding to demonstrate collective action.

Strategic priority 5: Enhance the advocacy role of the GHC This group concurred with the existing 3 actions for this strategic priority, but suggested some clarification as outlined below. The group felt the GHC has yet to demonstrate pro-active advocacy and therefore there was limited evidence base from which to suggest major changes to what remain critical advocacy objectives. 1. Support clusters to find solutions for the problems identified by the countries. 2. Advocate for resource mobilisation to cover the gaps in acute and protracted crises. 3. Promote the GHC publically, with decision makers and other stakeholders. During plenary feedback, participants stated overall that they felt the existing strategic priorities remained largely relevant whilst recognising that greater innovation was required to address cluster leadership, technical and operational capacity, designing and demonstrating the impact of cluster response and securing resources. HCCs committed to their continued engagement in the development of the new GHC strategy and will be invited to participate in the review of forthcoming drafts and other discussion fora.

Recommendations from Module 11:

GHC Unit to share draft strategy with HCCs for review and comments.

GHC Unit to ensure that HCC representatives of the GHC SAG seek feedback from other HCCs on key issues as required.

DAY 4-5: TRAINING ON THE ROLE OF HEALTH CLUSTER COORDINATORS ON PLANS, PROGRAMMES AND STRATEGIES AND RESOURCE MOBILIZATION Hyo-Jeong Kim and Cintia Diaz-Herrera conducted a two-day training on the role of HCCs on Plans, Programmes and Strategies and Resource Mobilization. The training was very well received by the participants, the main feedback being that additional time on the topics would have been beneficial. Presentations and background documents for the training are available at this Dropbox link: https://www.dropbox.com/sh/9ticr3c9ndd3qr6/AAAzwfsM6ERtiq3ZfXpfiN-Za?dl=0.

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Evaluation Training on the Role of Health Cluster Coordinators on Plans, Programmes (Hyo-Jeong Kim) The participative and interactive methodology (group work) was very much appreciated by the participants, together with the conceptual clarity. Some participants were concerned about not having had enough time as they would have liked to go through the module, however this was a challenge with only one day of training. Training on the Role of the Health Cluster Coordinators on Resource Mobilization (Cintia Diaz -Herrera) The evaluation of this session was conducted two weeks after the Forum. Participants were asked whether to retain all the proposed sessions and, if not, to suggest changes. 5 participants responded that all sessions were useful and had to be kept. It was suggested that more time be given to this module and to make it more interactive.

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Annex 1: List of Participants

Org. Participants Country office

City Email Address

AFRO

Mr Craig Hampton AFRO Brazzaville hamptonc@who.int

Dr Amadou Diallo Guinea Conakry dialloam@who.int

Dr Richard Fotsing CAR Bangui fotsingri@who.int

Dr Julius Wekesa South Sudan Juba wekesaj@who.int

Dr Daizo Arsene Chad N'Djamena daizoa@who.int

Dr K.M. Rosine Sama DRC Kinshasa samak@who.int

Dr Coulibaly Cheick Oumar Mali Bamako coulibalyc@who.int

Dr Innocent Nzeyimana Niger Niamey nzeyimanai@who.int

EMRO

Dr Muhammad Fawad Khan Pakistan Islamabad khanmu@pak.emro.who.int

Dr Shafiq Mohammad Pakistan Peshawar shafiqm@who.int

Ms Jennyfer Dulyx Amman Jordan dulyxj@who.int

Dr Iliana Mourad Libya Tunis mouradil@who.int

Dr Jamshed Tanoli Sudan Khartoum tanolij@who.int

Dr Iman Ahmed Yemen Sana'a ahmedi@who.int

Dr Mohammad Daoud Altaf Iraq Erbil altafm@who.int

EURO Dr Dorit Nitzan Kaluski Kiev Ukraine nitzankaluskid@who.int

SEARO Dr Gabriel Eduardo Novelo Sierra

Myanmar Yangon novelog@who.int

WPRO Dr Allison Gocotano Philippines Manila gocotanoa@who.int

AMRO/ PAHO

Dr Ciro Ugarte AMRO/PAHO Washington DC

ugarteci@paho.org

WHO HQ

Ms Linda Doull WHO HQ Geneva doulll@who.int

Dr Ahmed Zouiten WHO HQ Geneva zouitena@who.int

Ms Elisabetta Minelli WHO HQ Geneva minellie@who.int

Ms Antonia Pannell WHO HQ Geneva pannella@who.int

Mr Rick Brennan WHO HQ Geneva brennanr@who.int

Dr Michelle Gayer WHO HQ Geneva gayerm@who.int

Mr Xavier de Radiguez WHO HQ Geneva deradiguesx@who.int

Mr Samuel Petragallo WHO HQ Geneva petragallos@who.int

Dr Rudi Coninx WHO HQ Geneva coninxr@who.int

Mr Guillaume Simonian WHO HQ Geneva simoniang@who.int

Ms Hyo Joeng Kim WHO HQ Geneva kimhy@who.int

Ms Cintia Diaz Herrera WHO HQ Geneva diazherrerac@who.int

SAG / NGO Consortium

Dr Pascale Fritsch Helpage UK London pfritsch@helpage.org

Dr Richard Garfield CDC Atlanta chx8@cdc.gov

Mr Gerbrand Alkema Save the Children

London g.alkema@savethechildren.org.uk

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Annex 2: Summary of the Evaluation

Day 1: Monday 23 March

Module 1: WHAT’S NEW IN THE GLOBAL LEVEL? ; Chaired by Dr Richard Brennan

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

4

3

6

15

15

13

3

4

3

- Too many presentations - Dedicate more time for discussions - Great quality of presentations nonetheless - Some presenters are not on the subject - More on Prime

Module 2: HEALTH CLUSTER/SECTOR COORDINATION IN RECENT EMERGENCIES; Chaired by Ms. Linda Doull

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

4

2

5

13

16

13

5

4

4

Module 3: INFORMING STRATEGIC DECISION-MAKING IN THE HUMANITARIAN RESPONSE; Chaired by Dr Ciro Ugarte

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

1 1

2

2

14

15

15

6

5

5

30

Module 4: STRATEGIC RESPONSE PLANNING;

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

2

2

1

15

16

17

5

4

4

Day 2: Tuesday 24 March

Module 5: IMPLEMENTING AND MONITORING THE RESPONSE; Chaired by Dr Michelle Gayer

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

3

2

3

8

7

7

4

5

3

Module 6: MONITORING THE HEALTH CLUSTER PERFORMANCE; Chaired by Dr Ahmed Zouiten

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

2

3

3

9

6

8

4

6

4

Module 7: ENHANCING THE ROLE OF THE HEALTH CLUSTER IN PREPAREDNESS;

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

1

1

2

8

8

10

6

6

3

31

Module 8: TRANSITIONING OF CLUSTERS; Chaired by Dr Rudi Coninx

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

1 2

1

2

5

8

7

7

6

6

Day 3: Wednesday 24 March

Module 9: SUPPORTING THE HEALTH CLUSTERS TO PERFORM THE CLUSTER FUNCTIONS; Chaired by Dr Michelle Gayer

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

1

1

2

8

10

9

7

5

5

Module 10: LOOKING FORWARD – A NEW GLOBAL HEATLH CLUSTER STRATEGY: Chaired by - tbc

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

2

1

8

10

11

7

6

6

Module 11: STRENGTHENING SERVICE DELIVERY @ COUNTRY LEVEL: A MATTER OF ACCOUNTABILITY; Chaired by Dr A Zouiten

Very poor poor fair good great

- Did the session reach its objectives?

- Was the content relevant for your work at country level?

- Did you get to share your views on the subject

1

2

3

11

11

11

3

2

4

32

Overall HEALTH CLUSTER FORUM Evaluation

Very poor poor fair good great

How would you rate this edition of the HC Forum

8 7

What would you like to change for the next edition

1) For the next forum, please make sure to invite more cluster coordinators for greater experience sharing

2) More discussion and less presentations

3) Choose a better season for hosting the forum

4) Emphasize the conclusions and recommendations

5) Allow more time for exchange between HCCs (respect the 30 min for coffee breaks)

6) More group work

What are the three things you liked most about the Forum

1) Meeting other HCCS and discussing respective contexts

2) Great design of the agenda and the different sessions which brought all the matters encountered at country level in a

very productive way

3) Discussing with Linda and Ahmed, the needs and the way forward

4) Knowing that I’m not alone and can reach out to GHC, eye to eye discussions with other HCCs

5) Discussions and experience sharing

6) Recommendations for action

7) Openness and friendly atmosphere with the GHC Unit team

8) Great agenda and content

33

9) Assistance during the preparation of the presentation

What are the three things you disliked most about the Forum

1) Too many presentations

2) The weather

3) Important people missing from the Regional offices

4) Being locked in a room for 3 days

5) The venue was not up to the standard, especially the hotel rooms that were not clean, and the conference room with no

daylight, and poor lighting.

34

Annex 3: The Ideal Cluster Coordination Team

Emergency Grading

Cluster Coordination Team Functions & (Cost)

Health Cluster Coordinator

Information Management Officer

Data Manager Public Health Officer Communications

Other Functions/Expertise

Grade 3

Dedicated (P4)

Dedicated (P3)

Dedicated (P3)

Dedicated (P4)

Dedicated (P3)

Administration

Needs Assessment

FMT Coordinator

Technical Specialists

Advisors on cross-cutting issues

Grade 2

Dedicated (P4)

Dedicated (P3)

Dedicated (P3)

Dedicated (P4)

Dedicated (P3)

Grade 1

Dedicated or Double Hat (P4)

Dedicated or Double Hat (P3)

Dedicated or Double Hat (P2)

Double Hat (P3)

Double Hat (P3)

Ungraded

Double Hat (P4)

Double Hat (P3)

Double Hat (P2)

Double Hat (P3)

Double Hat (P3)