PAN AMERICAN HEALTH ORGANIZATION Pan American Sanitary Bureau, Regional Office of the

1. . • PAN AMERICAN HEALTH ORGANIZATION • Pan American Sanitary Bureau, Regional Office of the • WORLD HEALTH ORGANIZATION United Nations: Civil-Military Coordination and the Cluster System Dr. Ciro R. Ugarte Emergency Preparedness and Disaster Relief

2. Outline: • UN Humanitarian Civil-Military Coordination • UN Cluster System. • Challenges & opportunities of DOD / International Organizations Coordination.

3. UN Civil-Military Coordination • The focal point for UN civil-military coordination is the Civil-Military Coordination Section (CMCS) of OCHA. • CMCS often deploys a Coordination Officer to support field-effective mechanisms. • The most common interface mechanisms are: • Civil-Military Operations Centre (CMOC) • Civil-Military Cooperation House (CIMIC House) • Humanitarian Operation Centre (HOC)

4. UN Civil – Military Coordination • Humanitarian organizations and military forces have different mandates • Humanitarian organizations endeavour to provide assistance to affected populations based on assessed needs and on the humanitarian principles. • Civil defense units are deployed in a humanitarian crisis based on the agenda of their government. • Militaries are deployed with a specific security and political agenda or in support of a security and political agenda.

5. Range of civil-military relationship PEACE TIME COMBAT Low opportunities of CM cooperation / high risks for humanitarians of being drawn into conflict dynamics High opportunities of CM cooperation / low risks for humanitarians of being drawn into conflict dynamics

6. Principles on military-civilian relations • Humanitarian criteria to use/accept military assets. • Military assets unique and only as a last resort. • A humanitarian operation retains its civilian nature. • Follows principles of humanitarian assistance. • Avoid direct delivery of humanitarian assistance. • Retains its international and multilateral character.

7. UN Civil-Military coordination in the health sector • The mission of the Global Health Cluster (GHC) is to build consensus on humanitarian health priorities and related best practices, and strengthen system-wide capacities to ensure an effective and predictable response. • The GHC looks at how civil-military coordination might affect humanitarian agencies’ ability to access affected populations and provide health assistance. Global Health Cluster - Position Paper Civil-military coordination during humanitarian health action

8. Building a Stronger, More Predictable Humanitarian Response System

9. Changing Environment • Proliferation of humanitarian actors • Demands for more structured international responses • Changing role of the UN(less direct implementation, more standard-setting and facilitation, more capacity-building) • Competitive fundingenvironment • Increased public scrutinyofhumanitarian action

10. Whose reform? Inter-Agency Standing Committee (IASC) Composed of NGO consortia, Red Cross and Red Crescent Movement, IOM, World bank and UN agencies

11. FOUR PILLARS OF REFORM CLUSTER APPROACH Adequate capacity and predictable leadership in all sectors HUMANITARIAN COORDINATORS Effective leadership and coordination in humanitarian emergencies PARTNERSHIP Strong partnerships between UN and non-UN actors HUMANITARIAN FINANCING Adequate, timely and flexible financing

12. Cluster mechanism General Assembly Resolution 46/182 on humanitarian assistance: IASC (Inter Agency Standing Committee) • Cluster lead agencies identified, PAHO/WHO for health cluster, • UNICEF for WASH cluster and nutrition cluster • WFP for food • Others…

13. Links with Government and national authorities “Each State has the responsibility first and foremost to take care of the victims of natural disasters and other emergencies occurring on its territory. Hence, the affected State has the primary role in the initiation, organization, coordination, and implementation of humanitarian assistance within its territory.” UN General Assembly Resolution 46/182

14. AIM • High standards of predictability, accountability and partnership in all sectors or areas of activity • More strategic responses • Better prioritization of available resources

15. United Nations Cluster Approach

16. New global cluster leads Technical areas Nutrition UNICEF Water/Sanitation UNICEF Health WHO Emergency Shelter: Conflict IDPs UNHCR Disasters IFRC ‘Convenor’ Cross-cutting areas Camp Coord/Mgmt: Conflict IDPs UNHCR DisastersIOM Protection: Conflict IDPsUNHCR Disasters & civilians in conflict (non-IDPs) HCR/OHCHR/UNICEF Early Recovery UNDP Common service areas Logistics WFP Telecommunications OCHA/UNICEF/WFP

17. Responsibilities of global cluster leads • Standard setting • Standard setting and consolidation of ‘best practice’ • Building response capacity • Training and system development at local, regional and international levels • Surge capacity and standby rosters • Material stockpiles • Providing operational support • Emergency preparedness • Advocacy and resource mobilization

18. Designating sector/cluster leads at the country level The UN consults the host government and national/international humanitarian actors to determine priority sectors. The UN ensures lead agencies are designated for all the key sectors. Where possible, lead agencies at the country level should mirror those at the global level. Sector/cluster leads are the provider of last resort, subject to access, security and funding.

19. United Nations Cluster System

20. Cluster Approach in Haiti: Specific Challenges in Haiti: • Too many people • Civil-military cooperation • Over coordination (10 meetings a day) • Weakness of national authorities • No legal or formal authority of the cluster coordinator to triage….

21. External actors in Haiti,an unregulated industry • Urban SAR teams: from 30 countries (1,800 rescuers) • UN agencies • Red Cross societies • International NGOs • Bilateral non state institutions (universities) • Religious associations • Ad-hoc initiatives • Total of 43,000 Internationals

22. Health Cluster in Haiti

23. Coordination: the Health Cluster in Haiti • The Cluster began operating 3 days after the earthquake and a full time HC Coordinator. • By February 16, 390 agencies registered with the HC. • Sub-working : • primary care, • hospital care • referral system • medical supplies • rehabilitation.

24. Health Cluster in Haiti

25. Hospitals • Day 10: 8 foreign field hospitals/40 health facilities • Day 13: 12 foreign field hospitals( 2 ships)/ 48 health facilities • Day 15: first military hospital leaving, others schedule their departure • Day 21: two more hospital ships arrived • Day 24: 21 foreign field hospitals/91 health facilities Russian Field Hospital

26. Land based Foreign Field Hospitals: 21 • MSF (Doctors without borders): 5 field hospitals, 16 Operating theatres and 1,237 bed capacity, 800 internationals and over 3,000 nationals, 5,707 surgical interventions (first month 2,386; second 1,902 and third 1,419). No patients were rejected. • Israel military Hospital: arrived on day 4 1,100 treated patients. 242 surgical procedures under anesthesia were performed on 205 patients. Patients with brain injuries; paraplegia, low Glasgow coma score not accepted.

27. Other disasters • Bam: 11 FFH 550 beds /Ukrainian first • Banda Aceh: 9 FFH /Singapore first/beds? • Pakistan: 10 FFH/Turkish first/ 38 Cuban FFH??? • Costs/bed/day: +/- 2,000 USD • No FFH arrives early enough for trauma care Source: Karolinska/Sweden PDM vol 23.no 2, 2008

29. Challenges: • Field hospitals concentrate on what they do best. • Rapid turnover of patients to achieve efficient use of theatres. • No post op care. the least sophisticated facilities were the most overworked. • No referral system between facilities. • No internationally accepted standards but professional groups (military, Red Cross, MSF) developed their own guidelines.

30. The problems • Unacceptable practices. • Questions about clinical competencies. • Accountability and coordination. • Complementarity of deployed medical teams (trauma, plastic surgery, crush syndrome, post op, rehab.) • Better match btw supply and demand (time of arrival).

31. Opportunities: establishing an international registry of FMT (Foreign Medical Teams) • Faster deployment (if governments can rapidly identify and approve FMT). • Better complementarities. • Reduction of duplications or overlap. • Better transparency and coordination with national authorities/cluster • Donors encouraged to support a registered FMT.

32. Thinking big…

33. Other initiatives • Registration: database of foreign medical teams, no validation required. • Certification: technical evaluation, implies liability for the certifying agency (INSARAG classification). • Accreditation: formal compliance with predetermined standards: is usually voluntary. • Licensure: Government permission( UK, Spain). • Emergency surgery coalition( ESC).

34. The three wishes of the humanitarian organizations “We know what to do”, the military should provide: • Security … without inconvenience • Transport … at no cost • Communications... without controls

36. In normal times . . . ¡ I NEED A DOCTOR !

37. In disaster situations. . . DISASTER ZONE I NEED ONE DOCTOR!

38. Lessons Learned from Tsunami Recovery Key Propositions for Building Back Better Beneficiaries deserve the kind of agency partnerships that move beyond rivalry and unhealthy competition. A Report by the UN Secretary-General’s Special Envoy for Tsunami Recovery, William J. Clinton. December 2006

39. The real challenge: Coordination Hospitals INTERPOL CDC Donor countries USAID CIDA HHS DOD Private health centers ECHO MSF OAS CAPRADE Universities National Emergency Agency UK Ministry of health ACNUR SCR France CARE Japan PAHO WHO MC South Com FNUAP Netherlands WFP OXFAM ICRC Red Cross CEPREDENAC UNDAC ORAS CONHU Local NGO PRESS Health Canada CARITAS Security Church UNICEF IFRC CDERA Lessson…learned?

40. . • PAN AMERICAN HEALTH ORGANIZATION • Pan American Sanitary Bureau, Regional Office of the • WORLD HEALTH ORGANIZATION United Nations: Civil-Military Coordination and the Cluster System Dr. Ciro R. Ugarte Emergency Preparedness and Disaster Relief