Responding to COVID-19: Guidance for Humanitarian Agencies

"Humanitarian actors will need to make sure that the different functions of the response work are delivered in meaningful, coherent and inclusive ways for the most vulnerable and at-risk populations."

This tailored guidance document for developing a health response to the novel coronavirus disease 2019 (COVID-19) aims to assist frontline staff working on international, national, and local humanitarian responses to the pandemic. Developed by ALNAP/Overseas Development Institute (ODI), the London School of Hygiene and Tropical Medicine (LSHTM), and the Geneva Centre for Education and Research in Humanitarian Action (CERAH), the paper outlines 14 actions and 7 principles for humanitarian actors to consider in their COVID-19 responses in low- and middle-income countries (LMICs). It sets out operational lessons, integrating key findings from previous epidemic outbreaks, and offers guidance to humanitarian agencies in preparing, adapting, and scaling up their efforts in response to COVID-19. The insights and ideas may have implications for other humanitarian sectors - notably, water, sanitation, and hygiene (WASH), shelter, and food security and nutrition. As such, the paper emphasises the need for effective multistakeholder coordination.

The guidance is based on: (i) a literature review, distiling evidence and recommendations from 272 peer-reviewed papers on operational responses to COVID-19, previous relevant outbreak and epidemics responses (including Ebola, cholera, Middle East Respiratory Syndrome (MERS), and SARS), and related evaluations and synthesis reports from the ALNAP Humanitarian Evaluation and Learning and Performance (HELP) Library; and (ii) key informant interviews with 33 health programme implementers and leaders working on the COVID-19 response in humanitarian contexts.

Actions for humanitarian responders (with links to resources in each area provided in the paper):

1. Support national efforts to assess COVID-19 impacts and surge capacities - e.g., "Humanitarian organisations - especially national and local actors - have a specific role to play in ensuring that preparedness processes are as inclusive as possible, especially of the most vulnerable groups. Information on vulnerable groups may already be available through appropriate mechanisms, such as in-country focal points for gender, accountability to affected people (AAP), community engagement, and age and disability....[P]reparedness plans should also take into account existing surge capacities for responding to COVID-19. This includes the capacities of national and regional health systems and those of national and local civil society organisations (CSO), communities, the diaspora, faith groups and businesses....Information on surge capacity should be forecast and made available at the national level using existing tools."
2. Develop and communicate clear scenarios, guidance, and protocols - e.g., "Effective preparation will include pre-agreeing and sharing guidance and protocols for key activities, covering:
   • COVID-19-specific response guidelines and protocols for national, local and community workers
   • adaptation guidelines for all other essential health services
   • health information, education and communication (IEC) materials.

...International, national and local humanitarian organisations will need to work together to make globally available guidance contextually relevant and appropriate, paying careful attention to social and cultural norms and to local health system capacity."

3. Support integrated and coordinated decision-making and oversight - e.g., "It is critical to establish in a timely fashion the necessary command and operations and doing so will depend on the resources and sustained engagement of international, national and local actors. During the Ebola Outbreak in Sierra Leone, it took five months to establish command and control operations - due in large part to slow coordination among external donors and other actors..."
4. Prepare across the continuum, from community to health facilities - e.g., "Humanitarian actors should engage from the very start of the response affected communities and trusted sources, including survivors and community leaders...Lessons from the Ebola...response show that the predominance of top-down communication in the early stage of the response sidelined community engagement as a critical operational tool....As a result, Ebola messaging and response strategies often failed to meet the needs of and realities confronting affected populations....Community-level efforts should account for language, cultural and social factors around risk perception and risk management, and follow good principles followed in other COVID-19 responses ....Overly negative messaging can increase stigma, deter people from reporting symptoms and seeking treatment, and steer people away from health facilities and towards traditional healers or their families (where they may infect vulnerable relatives)."
5. Prioritise people, money, essential services, and goods - e.g., "Staffing options and needs based on different scenarios should from the outset be written into protocols and shared widely with all actors involved in the response..."
6. Ensure that personal protective equipment (PPE) for health workers and support staff is available - e.g., "Pre-positioning PPE stock and establishing and communicating protocols for why, when and how to use it are essential..."
7. Prioritise syndromic facility-based surveillance - e.g., "In settings where there are sufficient resources and capacities to collect, and more importantly, analyse data and to act on its findings, humanitarian actors should rely primarily on information from communities, either by putting in place or building on existing surveillance systems."
8. Adapt the testing approach to transmission scenarios and testing capacity - e.g., "[T]he Nigeria Centre for Disease Control has developed a flow chart to help health workers assess patients presenting with COVID-19 symptoms when they arrive at the health facility..."
9. Account for and support the most vulnerable groups - e.g., "Humanitarian actors...have a two-pronged role to play in targeting vulnerable individuals:
• Identifying and mapping populations vulnerable to COVID-19 (e.g. older people, those with comorbidities (other underlying health conditions), refugees or displaced peoples)
• Identifying the most appropriate channels by which to reach these populations (e.g. via institutional memory, existing relationships with specific groups to which target populations belong...

...Targeting approaches should be developed by working closely with health facilities, social services and community leaders."

10. Employ containment approaches to reduce transmission - e.g., "Humanitarian actors should work with relevant actors to advocate for major changes to the organisation and location of the most vulnerable groups (e.g. evacuating camps and releasing prisoners or rehousing slum residents) while ensuring that their basic needs and dignities continue to be met."
11. Support socially and economically sensitive approaches to quarantine and isolation - e.g., "Containment strategies undertaken or supported by humanitarian organisations and their partners needs to be clearly grounded in social and cultural contexts and be sensitive to existing economic inequities and vulnerabilities."
12. Implement WASH interventions for effective infection prevention and control - e.g., "To improve the community's acceptance of such measures, humanitarian organisations should dedicate resources to WASH communications campaigns."
13. Adapt health facilities and protocols - e.g., "This section sets out actions for two distinct scenarios that humanitarian actors may face, to enable them to organise the delivery of timely and quality care for suspected and confirmed COVID-19 patients in humanitarian settings."
14. Deliver appropriate and relevant critical care measures - e.g., "[I]t should be noted that an intensive care unit or critical-care-focused model for many humanitarian settings will be extremely challenging to comprehensively implement..."

Seven operational principles for effective responses include:

• Mobilise locally appropriate, joined-up community-led initiatives - e.g., "The international humanitarian sector has tended to learn the hard way the lesson about the importance of community engagement - if it has learned it at all....From the outset, humanitarian actors need to combine top-down planning and anticipation with more bottom-up, community-led approaches. Humanitarians also need to develop and use a systematic, testable and adaptable approach to support and mobilise communities from the very beginning."
• Support local actors to lead the response - e.g., "Significant resources must be allocated and channeled to those local organisations that are in the front line of epidemic prevention and response work. There is a particular need to ensure that local organisations do not become instrumentalised in the COVID-19 responses. This includes...providing a platform for local actors to have their voices heard at an international level."
• Work in politically and socially sensitive ways - e.g., "Terms such as 'community' and 'local actor' are powerful but also problematic. In the extreme, their unthinking use can lead to strategic and operational oversimplifications and allow humanitarian efforts to ignore political and social realities, differences and inequities."
• Keep in mind that duty of care for response workers at all levels is essential - e.g., "[A]ctively promot[e] duty-of-care competences among responding organisations, and facilitating online and social platforms for mutual support..."
• Establish and share ethical guidelines for the response - e.g., "[H]umanitarian actors should develop contextually appropriate ethical guideline packs, based on the response scenarios identified, and create communications learning materials and processes to ensure ethical mechanisms are accessible and understood by all relevant actors and stakeholders".
• Anticipate and work collectively to offset adverse secondary impacts - e.g., "How can we draw on all of the capabilities of the humanitarian system and on those of other national and local stakeholders - from government to private sector organisations, civil society to the media?"
• Invest in operational learning, research, and innovation efforts - e.g., "Where possible, enable and support country-level research and learning strategies, broadening networks, prioritising engagement with relevant universities, business groups and trade associations at national and potentially regional level."

Editor's note: On May 12 2020, ALNAP offered a webinar featuring a panel discussion and reflections upon the paper's actions and the challenges and opportunities different humanitarian actors are facing when putting them into practice. Click the video below to view it.