RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

Transcription

1 RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

2 IOM is committed to the principle that humane and orderly migration benefits migrants and society. As an intergovernmental organization, IOM acts with its partners in the international community to: assist in meeting the operational challenges of migration; advance understanding of migration issues; encourage social and economic development through migration; and uphold the human dignity and well-being of migrants. Publisher: International Organization for Migration Route des Morillons 17 P.O. Box Geneva 19 Switzerland Tel: Fax: International Organization for Migration (IOM) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior written permission of the publisher.

3 Core components of IOM's Health, Border and Mobility Management (HBMM) framework in action: IOM staff interact with travellers to collect mobility pattern data on mobile devices, raise awareness about infectious diseases, and institute effective infection prevention and control at a border post in Kourémalé, Mali IOM a tenuous relief would fill the voices of doctors who talked of how fortunate it was for humankind that this new killer had awakened in this most remote corner of the world and had been stamped out so quickly. A site just a bit closer to regional crossroads could have unleashed a horrible plague. With modern roads and jet travel, no corner of the earth was very remote anymore; never again could diseases linger undetected for centuries among a distant people without finding some route to fan out across the planet. [1987 commentary on the initial 1976 Ebola Virus Disease (EVD) outbreak by Randy Shilts in what was then Zaire (now DRC)][i] The ongoing Ebola outbreak is taking place in one of the most highly connected and densely populated regions of Africa. Accurate information on population movements is valuable for monitoring the progression of the outbreak, predicting its future spread, facilitating the prioritization of interventions and designing surveillance and containment strategies Wesolowski, A. et al. (2014) PLoS Currents Journal, 29 September 2014

4 TABLE OF CONTENTS Foreword Glossary of Acronyms IOM Vision for Ebola Recovery Background The Ebola Crisis in West Africa: Current Perspectives Human Mobility and the EVD Crisis The Global Health Security Agenda IOM Instruments to Emergency Response IOM s EVD Response through the Migration Crisis Operational Framework (MCOF) Strength of IOM in Ebola Response and Transition Towards Recovery IOM s Programmatic Areas for Ebola Recovery Enabling Community Resilience and Restoring Essential Services Restoring the Functionality of Key Government Systems Activities to support Social Cohesion, Resilience Building, and Disaster Risk Reduction Counter-Trafficking and Protection of Vulnerable Migrants Technical Assistance for Humanitarian Border Management (HBM) Leveraging Diaspora Engagement to support Post-Ebola Reconstruction Efforts Facilitating Labour Mobility for Enhanced Resilience Health, Border and Mobility Management (HBMM) The Mobility Continuum: Stages of Mobility and Spaces of Vulnerability The Four Pillars of the HBMM Framework Unpacking the 10 Components of the HBMM Framework Cross-Cutting Pillar: Training and Capacity Building Tables Annexure Annex 1. Meaningful Engagement of Diaspora Professionals in Contributing to Recovery Efforts...29 Annex 2. IOM African Capacity Building Centre...30 Annex 3: Defining Intervention Strategies along the 3 Stages of an Epidemic Curve Country Strategies Guinea Liberia Sierra Leone Côte d Ivoire Ghana Mali Senegal... 56

5 FOREWORD The International Organization for Migration affirms its commitment to supporting Ebola Virus Disease Recovery plans, presented at this conference, and stay the course until we get to zero, maintain zero and build back better. Human mobility is a critical factor in the spread of Ebola virus, which is taking place in a West African region where there is intensive cross-border travel between countries. Despite border closures observed during outbreaks, economic needs push many to seek alternative routes of entry and exit along porous border crossings, further complicating containment efforts. Innovative and evidence-based strategies are needed to effectively protect public health, whilst mitigating the negative economic impact through the loss of cross-border trade. Early after the UN Secretary General s call to the international community to respond to the Ebola Crisis in August 2014, IOM was able to quickly leverage our field presence, through the network of peripheral offices at country level, and mount an effective response to identified needs. IOM s Early Response efforts included the management of Ebola Treatment Units in Liberia, support for Emergency Operation Centres in Guinea, and training of front-line responders in Infection Prevention and Control (IPC) in Sierra Leone. IOM s Migration Crisis Operational Framework (MCOF), our core emergency and humanitarian, organizationwide, response procedure, was activated it enables the Organization to respond to crisis-affected communities, including within public health emergencies, in a coordinated, adaptive, multi-disciplinary and cross-sectoral manner. Staying the course of response, IOM s contribution to the Ebola Recovery strategy is now built on three inter-connected, programmatic areas of work: 1) Health, Border and Mobility Management aims to prevent and tackle the spread of virus, through disease prevention, detection and response activities along mobility corridors and in cross-border areas, while enhancing local health systems, inter-sectoral partnership, and inter-country cooperation. 2) Community resilience and restoring essential services interventions for restoring normalcy and promoting resiliency of affected communities can be achieved through implementation of targeted, evidence-informed interventions to enhance livelihood, infrastructure, and essential health and social services, including programmes on community mobilization and psychosocial support. Women at border communities, who play a vital role in sectors of the economy, such as informal trade that has been adversely affected by the outbreak, should be particularly supported through livelihood recovery programmes, integrated with interventions that protect vulnerable groups against trafficking and exploitation. 3) Training and capacity building is a key to recovery. Building on the experience of the Regional Training Academy in Sierra Leone that has successfully trained over 8,000 health workers and is currently the largest Infection, Prevention and Control (IPC) training facility in West Africa, IOM will continue to provide training and capacity building to different professional cadres, community leaders, and various responders with diversified curricula during the recovery phase, both at central and community levels. IOM has also engaged the diaspora of health professionals living in Germany, USA, UK and Canada, who are willing to return on long-term basis to assist in recovery efforts. The IOM Ebola recovery strategy is built upon the foundations of Member States proprietorship, partnership, innovation, accountability, and experience in developing highly successful, capacity building programmes and intersectoral cooperation in the African region. Ambassador William Lacy Swing address at the UN Ebola Recovery Conference New York 10 July 2015 RECOVERING FROM THE EBOLA CRISIS A STRATEGIC FRAMEWORK FOR ACTION

6 GLOSSARY OF ACRONYMS CDC CEBS COMAHS DOE DRR ECDC ECOWAS EOC ERA ETU EVD FMT GHS HBMM HIA IASC IDSR IEC IHR IPC MCOF MHD MIDAS MMPs NEOC NGO PEOC PHEIC PoE PPE PSS SAG SOP SQS UHC VPD WHO Centers for Disease Control and Prevention Community Event Based Surveillance College of Medicine and Allied Health Sciences Department of Operations and Emergencies (IOM) Disaster Risk Reduction European Centre for Disease Prevention and Control Economic Community of West African States Emergency Operations Center United Nations Ebola Recovery Assessment Ebola Treatment Unit Ebola Virus Disease Foreign Medical Team Global Health Security Health, Border and Mobility Management Health Impact Assessment Inter-Agency Steering Committee Integrated Disease Surveillance and Response Information, Education and Communication International Health Regulations Infection Prevention and Control Migration Crisis Operational Framework (IOM) Migration Health Division (IOM) Migration Information and Data Analysis System (IOM) Migrants and Mobile Populations National Emergency Operations Centre Non-Governmental Organization Prefectural Emergency Operations Centre Public Health Emergency of International Concern Point of Entry Personal Protection Equipment Psychosocial Support Services Strategic Advisory Group of the Global Cluster on Early Recovery Standard Operating Procedure Safe and Quality Health Services Universal Health Coverage Vaccine-Preventable Disease World Health Organization 02 INTERNATIONAL ORGANIZATION FOR MIGRATION

7 IOM VISION FOR EBOLA RECOVERY IOM is firmly committed to staying on course on getting to and maintaining zero Ebola cases and being supportive of recovery plans, proposed by Ebola-affected Governments for building back better. IOM seeks to support member states in the development of evidence-informed, high-impact interventions to protect the public health of communities, migrants and mobile populations, during outbreaks and other emergencies, by catalysing inter-sectoral cooperation to build resilient communities and systems. Minimizing the negative impact on trade, commercial activities, and free flow of people across borders is a key priority in implementing these interventions. Strategies to address health vulnerabilities that exist along mobility corridors, through a primary health care and intersectoral systems strengthening approach, will ultimately promote Global Health Security and Global Health goals in this highly interconnected African region. IOM supports the free and healthy movement of people and migration in the region, as a critical element for socioeconomic development and rebuilding. RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

8 1. BACKGROUND The 2014/2015 Ebola Virus Disease (EVD) outbreak in Guinea, Liberia and Sierra Leone, which also affected neighbouring countries, Nigeria, Senegal, and Mali, has been unprecedented in its scale and impact, in terms of human loss, economic drain, and delayed development for countries within the region. The EVD outbreak of 2014/2015 in West Africa was declared a Global Health Emergency 1 on 8 August 2014 and was in fact two crises in one: 1) A crisis of a virulent, epidemic disease with more than 28,600 infected persons and over 11,300 deaths, including 513 deaths of health care workers (WHO Situation Report data, as of 13 December 2015); and 2) A crisis of systems that were unable to address the challenges of EVD in health services and public health, consequentially crippling other governmental systems, including education, food security, finance, and more THE EBOLA CRISIS IN WEST AFRICA: CURRENT PERSPECTIVES Though currently in a phase of low and residual transmission, the EVD epidemic is not yet over. Getting to zero, and maintaining zero EVD cases requires intensive public health vigilance and leadership (see Figure 1). The Ebola virus is also leaving an indelible mark on survivors. Whilst the general community and government narrative has been to characterize survivors as heroes, evidence of stigma and marginalization has also been noted. 2 Survivors have increasingly become critically important to prevent EVD reintroduction. Emerging findings, amassed by tracking unprecedented numbers of people who recovered from the disease in West Africa, suggest that survivors, who were pregnant when they were infected, can pass the virus to the foetus. The virus has also been detected in the placenta and semen. 3 Therefore, surveillance and early detection of new cases remain critical elements in the post-ebola-crisis phase. The strategic objective of the Ebola response continues to be to stop the transmission of EVD in the shortest possible time-frame and achieve this in a manner that builds the community, the economy, and health system resilience. Ending the epidemic and Figure 1:: The challenge of "getting to zero, and maintaining zero Liberia was declared free of Ebola on 9 May 2015, after reporting no new cases for 42 consecutive days. The country subsequently entered a 3-month period of heightened surveillance, during which blood samples and oral swabs were collected daily from potential cases and tested for EVD. On 29 June, this heightened surveillance detected an EVDpositive, community death in Margibi County, the first newly confirmed case reported in Liberia, since 20 March avoiding its resurgence will require continuous vigilance and concerted efforts by all government sectors, not just health systems alone. While rigorously applied disease prevention, detection and response measures will eventually bring the EVD outbreak to an end, addressing the systems crisis requires sustained country leadership, increased community participation, and the continuous support of partners in the international community. IOM is firmly committed to staying the course HUMAN MOBILITY AND THE EVD CRISIS Human mobility is a critical factor in the rapid spread of the EVD epidemic. 4 Internal migration and cross-border mobility for purposes of formal/informal trade, cultural events, employment, education and health, remain an essential part of life for many communities in West Africa, where the free movement of people, goods and services is considered key for regional integration, prosperity and development. 5 The Kissi triangle cross-border region, at the intersection between Sierra Leone, Liberia and Guinea, critical for trade 1 More specifically a Public Health Emergency of International Concern (PHEIC). PHEIC is a formal declaration by the World Health Organization (WHO) promulgated by that body s Emergency Committee operating under International Health Regulations (IHR) of a public health crisis of potentially global reach. 2 Lee-Kwan, S. H., DeLuca, N., Adams, M., Dalling, M., Drevlow, E., Gassama, G., & Davies, T. (2014). Support services for survivors of Ebola virus disease-sierra Leone, MMWR. Morbidity and mortality weekly report, 63(50), Christie, A., Davies-Wayne, G. J., Cordier-Lasalle, T., Blackley, D. J., Laney, A. S., Williams, D. E., & De Cock, K. M. (2015). Possible sexual transmission of Ebola virus-liberia, MMWR. Morbidity and mortality weekly report, 64(17), A range of Socio-cultural, Environmental, and demographic factors influencing spread of EVD: a) Traditional cultural practices, such as funeral rites/indigenous rituals; b) Food habits (consumption of local fauna/ bush meat ); c) Health seeking behaviour (allopathic vs. indigenous medicine); d) Mistrust of health and government services; e) Health services weakened by protracted conflict, poor governance and lack of investment; f) human mobility (international air and sea travel, cross-border movement for purpose of labour migration, trade, leisure, and/or settlement); and, g) Deforestation and encroachment to habitats of animal reservoirs that increase chances of zoonotic transmission. 5 Adepoju, A. (2007). Creating a borderless West Africa: constraints and prospects for intra-regional migration. Migration without Borders, INTERNATIONAL ORGANIZATION FOR MIGRATION

9 IOM supports Sierra Leonean authorities to monitor travellers for overt signs of illness and collect mobility data at the Mange screening post, located in the Forécariah-Kambia area between Guinea and Sierra Leone, epicentre of sustained EVD transmission, along the heavily-trafficked corridor connecting Conakry and Freetown IOM 2015 and commerce, was at the epicentre of a protracted war over a decade ago and in 2014 became the epicentre for EVD spread. The Forécariah-Kambia axis between Guinea and Sierra Leone is another example of the contribution population mobility made in sustained transmission of the virus. During the month of July (2015) alone, 4 out of the 7 transmission chains of positive EVD cases identified in Kambia (Sierra Leone) were linked with positive EVD cases in Forécariah (Guinea). Communities residing on both sides of the border share strong familial ties. Cross-border movement is a part of these communities daily lives and takes place mostly through unregulated border crossing points. Restrictions to human mobility were enforced by authorities in some settings to inhibit cross-border movements with the rationale for containment of EVD spread. However, the true impact of such measures in curtailing the spread of EVD is yet unknown. The impact on trade and on the economy of the affected and neighbouring countries suffered tremendously with an overall forgone output, in just the three most affected countries of 1.6 billion USD (12% of the combined GDPs). 6 The need to adopt evidence-informed methods to determine corridors of population movements and for understanding the primary drivers of human mobility is vital for targeted prevention, detection, and response efforts, especially at border areas, while safeguarding countries trade and economic interests THE GLOBAL HEALTH SECURITY AGENDA The EVD epidemic has brought renewed attention and impetus towards Global Health Security (GHS) 7 goals and the implementation of International Health Regulations (IHR). 8 An interconnected world is increasing the opportunities for human, animal and zoonotic diseases to emerge and spread globally. 9 Today s GHS threats arise from a number of sources, amongst these are: The emergence and spread of new microbes, also linked to human pressure on nature and ecology; The emergence and spread of drug-resistant pathogens; The acceleration of biological science capabilities and the risk such capabilities have in causing inadvertent or intentional release of pathogens; The globalization of travel and food supply; 6 The Economic Impact of Ebola on Sub-Saharan Africa: Updated Estimates for The World Bank Group. 7 The World Health Organization (WHO) defines global health security as the activities required to reduce the vulnerability of people around the world to new, acute, or rapidly spreading risk to health, particularly those that threaten to cross international borders WHO, The World Report 2007 A Safer Future: Global Public Health and Security in the 21st Century. 8 The International Health Regulations (IHR) are an international legal instrument that is binding on 196 countries across the globe, including all the Member States of WHO. Their aim is to help the international community prevent and respond to acute public health risks that have the potential to cross-borders and threaten people worldwide. The IHR, entered into force on 15 June This has called for a One Health approach, the collaborative effort of multiple disciplines working locally, nationally and globally to attain optimal health for people, animals and the environment. RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

10 Urbanization, human density and human mobility; The persistence of disparities and inequities in accessing Universal Health Coverage (UHC) in many areas of the world, amongst strata of societies, and between nationals and foreign-born. It is clear that bridging health, human mobility and border management capacities at national, regional and global levels is essential to achieving GHS goals, and are within the scope and expertise of IOM IOM INSTRUMENTS TO EMERGENCY RESPONSE The foundation of IOM s emergency response, globally, is the Migration Crisis Operational Framework (MCOF), adopted by IOM member states in 2012, and the participation within the humanitarian Inter-Agency Steering Committee (IASC) Cluster System. IOM responds to the needs of its 162 Member States, with operations in over 400 locations in 142 countries worldwide, including the West African Ebola-affected countries. Out of some 9,000 IOM staff deployed at field level, more than 1,000 are involved in the implementation of health programmes in some 60 countries, including in the context of crises. IOM is a leading agency in advancing the migration health and human mobility agenda, globally, with an extensive network of 55 Migration Health Assessment Centres worldwide, including a large network of partners ranging from direct medical care providers to research and advocacy institutions for policy change. These include such actors as the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (CDC), and the European Centre for Disease Prevention and Control (ECDC). IOM is a member of the Global Health Cluster led by WHO, and is an active responder to various health emergencies. IOM also works with Governments in responding to the avian influenza pandemic, the HIV/ AIDS epidemic, Multi-Drug Resistant Tuberculosis cases, malaria, and other various Vaccine-Preventable Diseases (VPD) with a focus on migrant and mobile populations. In the years 2008 to 2010, IOM was part of the UN Pandemic Preparedness response in the wake of the H1N1 influenza pandemic, and implemented pandemic preparedness projects in countries, such as Cambodia, Egypt, Indonesia, Kenya, Lao PDR, Nigeria, Thailand and Vietnam. Following the declaration of the EVD outbreak as a PHEIC in September 2014, the Director General of IOM, Ambassador William Swing, reached out to member Figure 2:: Key features of the IOM - MCOF Combines IOM humanitarian and development activities and migration management services in 15 sectors of assistance, such as logistic/operations, health, psychosocial support to counter-trafficking. Covers pre-crisis preparedness, emergency response and post-crisis recovery. Is based on international humanitarian and human rights law, and humanitarian principles. Complements existing international/humanitarian systems (e.g. Cluster Approach) and builds on IOM s partnerships. Helps crisis-affected populations, including displaced persons and vulnerable migrants to better access their fundamental rights to protection and assistance. states, UN partners and donors to declare the Ebola crisis as an internal Level 3 emergency (L3). The L3 implies an Organization-wide priority response led by core experts and departments in Headquarters, the IOM Regional Office for West and Central Africa, and all IOM Missions present in the affected countries and surrounding ring countries. Following the L3 procedures, the Directors of the Migration Health Division (MHD) and Department of Operations and Emergencies (DOE) provided shared leadership and oversight to IOM s Ebola response programmes and projects in order to maximize the result of the overall response across the different countries. 06 INTERNATIONAL ORGANIZATION FOR MIGRATION

11 2. IOM S EVD RESPONSE THROUGH THE MIGRATION CRISIS OPERATIONAL FRAMEWORK (MCOF) IOM s MCOF (see Figure 2) complements existing international protection systems, and is meant to improve IOM s performance within these systems. The Framework thus allows the organization to respond to emergencies and migration crises in a coordinated, interconnected and interdisciplinary way. Furthermore, the MCOF enables a number of operational and migration management tools that can supplement the humanitarian response, such as health care and complex logistics, technical assistance in humanitarian border management, liaison and coordination to ensure that affected populations have access to emergency services, referral systems for persons with special protection needs, training and capacity building at multi-sectoral levels, as well as community mobilization. IOM s approach in the EVD Outbreak Response was anchored within three thematic areas: 1. Health Systems Support, 2. Health, Border and Mobility Management, and 3. Capacity Building activities. An overview of key interventions within each of these thematic areas in the response phase is listed below. HEALTH SYSTEMS SUPPORT: STRENGTHENING HOST GOVERNMENTS MINISTRIES OF HEALTH AND HEALTH CARE SYSTEMS Strengthening of EVD response through Ebola Treatment Units (ETUs) operations and Foreign Medical Teams (FMTs) deployment to effectively contribute to getting to zero and maintaining Zero cases. IOM managed Three ETUs in Liberia in Tubmanburg, Sinje and Buchanan. Clinical trainings, support access to existing health care and referral services to ensure continuity of health care for affected communities, engage in border and community health needs assessments and gap analysis to inform border health authorities and mitigate cross-border and health risk re-importation of Ebola into Liberia. As a stopgap measure following the high transmission phase of the Ebola crisis, IOM implemented Mobile Clinics to restore essential health services in Liberia IOM 2015 RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

12 IOM staff conducting a Safe and Quality Health Services (SQS) training, a package designed by the Ministry of Health in Liberia IOM 2015 Strengthening of the National Emergency Operations Centre (NEOC) and refurbishment of 28 Prefectural Emergency Operations Centres (PEOCs), as well as rehabilitation of Ministry of Health buildings in Guinea. Collaboration with the national government and partners for a harmonized and integrated systems approach, which includes physical rehabilitation, staffing and training capabilities for Emergency Operations Centers (EOCs) in Liberia. To strengthen health systems, IOM also provides Safe and Quality Health Services (SQS) training to healthcare workers, covering such topics as Infection Prevention and Control (IPC) standard precautions; disease surveillance, clinical emergency management, and psychosocial support. Training of 100 volunteers, community leaders and Ebola survivors on effective IPC measures in Sierra Leone. Community Mobilization and distribution of interim care kits in the Western Area, Bombali and Kono districts of Sierra Leone; active case finding at markets, sensitization about ETUs, immunization, and swabbing of dead bodies in communities in Liberia throughout Bomi, Grand Bassa and Grand Cape Mount counties; as well as public outreach campaigns in Côte d Ivoire and Guinea-Conakry. Upgrading IPC (isolation and triage) in health facilities, as well as WASH in schools, in Liberia. Support service delivery and active surveillance through mobile clinics in Liberia. Providing psychosocial support to reintegrate survivors into communities in Liberia. HEALTH, BORDER AND MOBILITY MANAGEMENT (HBMM) IN EIGHT WEST AFRICAN COUNTRIES Health screening and the establishment of Standard Operating Procedures (SOPs) at international airports and points of entry/exit in Sierra Leone, Mali, Ghana, and Côte d Ivoire, as well as at various internal screening points within Sierra Leone, Guinea, Liberia and Mali. Monitoring of mobility flows within the framework of EVD screening and traveller sensitization at 15 points of entry in Mali, 3 in Guinea, 7 in Liberia, and 10 in Sierra Leone. EVD preparedness activities, such as training of border personnel, surveillance, and reinforcement of community engagement in Côte d Ivoire, Liberia, Senegal, Burkina Faso and Ghana. Rehabilitation of border posts and PEOCs in Côte d Ivoire, along the border with Liberia and Guinea, and improvement of IPC measures at border posts in Liberia. 08 INTERNATIONAL ORGANIZATION FOR MIGRATION

13 Strengthening the capacity of border health and non-health staff to identify and refer suspect EVD cases with the appropriate personal protection equipment (PPE) and IPC procedures in the three affected and five ring countries TRAINING OF NATIONAL AND INTERNATIONAL HEALTH PERSONNEL AND HYGIENISTS, THROUGH THE NATIONAL TRAINING ACADEMY IN SIERRA LEONE, AS CORE TO RESPONSE, TRANSITION, AND RECOVERY PROGRAMMES The National Ebola Training Academy in partnership with the College of Medicine and Allied Health Services (COMAHS) in Sierra Leone provides modular Clinical, Infection Prevention and Control (IPC), and Person Protective Equipment (PPE) training for front-line Ebola and non-ebola medical practitioners. 8,244 course individuals (7,705 national; 539 international) certified to date, with participants receiving practical training in a mock Ebola Treatment Centre, where 10 EVD survivors serve as patient simulators. Mobile Training teams are rapidly deployed to remote areas in need of training (598 national and 24 international participants trained). Social Mobilization and Community Outreach IOM Psychosocial Support intervention teams offered individual counselling and group therapy to school children, mainly Ebola survivors, orphans and residents of highly affected communities, providing them an outlet to express themselves and process changes in their personal lives. IOM produced an extensive range of Information, Education and Communication (IEC) materials to promote EVD awareness, health education, and social mobilization STRENGTH OF IOM IN EBOLA RESPONSE AND TRANSITION TOWARDS RECOVERY The strength of IOM s emergency response has been two-fold. First, is the organization's strong operational and flexible multi-disciplinary approach in disaster response. Second, is its unique expertise in the field of human mobility and humanitarian border management. These strengths enabled the organization to provide a range of interventions through phases of high EVD virus transmission to phases of low transmission. Interventions ranged from providing lifesaving clinical care to Ebola patients, public health action to mitigate disease transmission, and support to Governments towards health systems recovery. OPERATIONAL CAPACITY AND FLEXIBILITY Following the IOM Director General s Level 3 Declaration for the Ebola Response, IOM mobilized technical experts from within the organization and globally through an innovative international recruitment process. These highly trained medical specialists and experts assisted in the Emergency Treatment Units (ETUs), Public Health Response, Psychosocial support and field operations. Subsequently, IOM launched its first response initiative in Liberia in October 2014, intervening in a critical area of need by opening and operationalizing three ETUs. This undertaking involved a complex and massive logistics operation, requiring strong hospital management and infectious disease control expertise. This skills set was crucial to ensure adequate treatment capacity and proper patient care, as well as uphold the safety of all patients and personnel. To date, IOM has maintained its reputation of not having a single infection among its personnel. With 2 out of its 3 ETUs in Liberia already decommissioned, IOM is now transitioning to becoming a key partner to support strengthening of Liberia s health system. IOM s ETU personnel have mobilized to support the provision of essential primary health care services. A key achievement of this initiative to date is the reactivation of routine immunization for children, the provision of essential care through mobile medical teams and support to existing health facilities. A core priority has been the promotion of Infection Prevention and Control (IPC) and restoration of Safe, Quality Services (SQS). Indeed, IOM is a lead partner in delivering SQS trainings in the three affected counties, and is on track to train more than 1,000 health care workers. IOM continues to contribute to and promote the inclusion of the mobility lens within the National Surveillance Committee that in responsible for enhancing the country s new disease surveillance strategy. Shortly after the opening of the first ETU in Liberia, IOM initiated its capacity building and community mobilization in Sierra Leone. On 1st December 2014, IOM formally took over the management of the Ebola training Academy from the UK Ministry of Defence located at a football stadium, with the capacity to train 800 trainees per course. To date, over 8,000 individuals have graduated from this EVD training course. Support has also been adapted to include in-service trainings at peripheral health institutions. RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

14 Mobile Training unit delivers Infection Prevention and Control (IPC) and clinical EVD training to front-line responders in Bombali District, Sierra Leone IOM 2015 In Guinea, IOM s contribution to the fight against EVD was immediately directed to strengthening the national emergency coordination capacity. Utilizing physical retrofitting of Prefectural Emergency Operation Centres (PEOCs) as an entry point, IOM has now established the much needed presence and trust by the Guinean government and key partners to sustain the built operational and public health capacity of Guinea s network of Emergency Operation Centres (EOCs). THE HUMAN MOBILITY DIMENSION Although IOM s position during the acute phase of the response was in responding to urgent health and operational gaps in order to save lives, the Organization soon aligned its EVD response across the three affected countries and neighbouring ring countries by implementing the Health, Border and Mobility Management (HBMM) framework. At the centre of this initiative is the realization that by better understanding population mobility, more targeted and evidence informed responses can be mounted at critical locations along human mobility pathways. Enhancing national capacities to better prevent, detect and respond to any future disease outbreaks and other health threats along such pathways is also emphasised. Despite significant epidemiological changes suggesting the end of the EVD outbreak, virus transmission persists in certain hotspots in Guinea and Sierra Leone, from where new cases continue to be reported. A substantial proportion of these cases share cross-border epidemiological links, such as cases reported in Kambia in Sierra Leone with those reported in Forécariah in Guinea. Several cases reported in Freetown were also linked with those in Port Loko (both are districts of Sierra Leone). Despite the correlation between population mobility and EVD incidence, to date, there has been a scarcity of empirical research to specifically explore such associations and the vulnerability to EVD transmission along the entire human mobility continuum. Better understanding of such cross-border movements is vital. 10 INTERNATIONAL ORGANIZATION FOR MIGRATION

15 IOM started mapping cross-border and in-country population flows between Guinea and Mali as early as December This information was then mapped against epidemiological data, enabling further analysis on vulnerabilities of travellers along their mobility continuum. Similar initiatives were subsequently set up at the Forécariah-Kambia border, and at the Liberian-Sierra Leonean border. Mobility mapping has since then been expanded to include several sea landing points along Freetown and Port Loko s shores, as well as internal movement between Kambia and Port Loko Districts in Sierra Leone. In all these locations, IOM supported health screening and installation of IPC measures, boosting the surveillance and response capacity of these three worst affected countries and their neighbours. Further, in order to ensure sustainability and the integration of mobility mapping into national surveillance structures, IOM teams in each country work hand in hand with their ministries of Health, WHO and other partners to incorporate mobility mapping within Community Event Based Surveillance (CEBS) and/or the Integrated Disease Surveillance and Response (IDSR) mechanisms. Through these mobility mapping efforts, IOM is increasingly recognized as a technical health partner, able to address a major knowledge gap: mobility and its related spaces of vulnerabilities vis-à-vis disease transmission. Indeed, the notion that a better understanding of human mobility is crucial to prevent, detect and respond to health threats, including communicable diseases, is gaining momentum, which IOM, due to the nature of its mandate, has been in the best position to act upon. In March 2015, recognizing the need to strengthen organization-wide collaboration on cross-border health management in support of respective organization s efforts to get to zero, IOM, CDC and WHO agreed to establish a working group. The Cross-border Health Working Group, through its weekly discussions, aims at better understanding cross-border and internal population mobility patterns and develop technical tools to better prevent, detect and respond to health threats and contribute to strengthening of country and regional level core capacities needed to implement International Health Regulations (IHR). IOM believes that preparedness, response and recovery of health crises need to be multi-sectoral, be responsive to population mobility and cross-border dynamics, engaging multi-agencies in both response and resilient recovery, and reflective of vulnerability spaces along mobility pathways. Supporting a safer human mobility for trade, work, and development is also necessary to enable community resilience and for restoring the positive path of socio-economic growth the affected countries were following after many years of political unrest. This should necessarily include awareness and protection of vulnerable individuals who have lost family and social capital resulting from the EVD crisis such women and youth, against the risks of exploitative and deceptive migration routes. 3. IOM S PROGRAMMATIC AREAS FOR EBOLA RECOVERY The strategic framework for recovery is based on the understanding that States bear the primary responsibility to protect and assist crisis affected persons residing on their territory in a manner consistent with international humanitarian and human rights law. IOM supports States, upon their request and with their consent, to fulfil their responsibilities. The country-specific Ebola recovery plans, the UN Ebola Recovery Assessment (ERA), and the Mano River Union subregional plan have all identified the scope for Ebola Recovery along five priority strategies, to which IOM intends to contribute, namely: 1. Stopping the Epidemic; 2. Risk-management; 3. Restoring and Strengthening Capacity; 4. Restoring Livelihoods and Building Community Resilience; and 5.Addressing Structural Factors. Figure 3 (below) visually depicts the broad conceptual Framework for Ebola recovery and resilience in Guinea, Liberia and Sierra Leone and in surrounding ring countries. These three programmatic areas are built upon the foundations of collaborative partnerships with the goal of achieving individual health security and more broadly regional and global health security by targeted health interventions at the nexus of human mobility. Ultimately, IOM seeks to support member states, regional governance structures, global partners and civil society to develop effective strategies to enable cross-border movement, trade and economic activities, whilst ensuring public health protection and resilience of communities and systems. RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

16 Figure 3:: IOM Broad Conceptual Framework for Ebola Recovery and Resilience in Guinea, Liberia, Sierra Leone, and surrounding Ring Countries IOM s broad conceptual Framework for Ebola recovery in Guinea, Liberia and Sierra Leone and surrounding Ring countries Key Strategies for Ebola Recovery & IOM s 3 Programmatic areas of work: 3. ENABLING COMMUNITY RESILIENCE AND RESTORING ESSENTIAL SERVICES Aims at revitalizing and restoring functionaliy of essential human services and facilitlies especially in cross-border areas 1. HEALTH, BORDER AND MOBILITY MANAGEMENT (HBMM) Public health action that aims at getting to zero, maintaining zero EVD cases thus supporting GHS Addressing structural factors Restoring livelihoods and building community resilience Restoring and strengthening capacity Risk management Stopping the epidemic 2. TRAINING AND CAPACITY BUILDING Goals Getting to Zero and Maintaining Zero EVD Cases Promoting Global Health Security (GHS) through targeted, evidence-based interventions Building back better resilient health systems and resilient communities Migration Crisis Operational Framework: 7 Relevant areas for Ebola recovery Health Support Counter Trafficking and Protection of Vulnerable Migrants & Mobile pops Community Stabilization and Transition Disaster Risk Reduction and Resilience Building Humanitarian Border Management Psychosocial Support Diaspora and human resource mobilization Within these priorities, the relevance of addressing vulnerabilities and public health challenges arising from intensive cross-border migration and mobility within the region has been emphasized (see Figure 4), as well as the need to enhance essential services and livelihood of affected communities and building capacities of different actors for risk reduction, resilience and development. Harnessing the lessons learned through IOM's EVD response with the vision to build back better, the following programmatic areas outline the organization s overall strategy for Ebola recovery: 3.1 Enabling Community Resilience and Restoring Essential Service 3.2 Health, Border and Mobility Management (HBMM) 3.3 Training and Capacity Building activities (Cross Cutting Domain of Work) 12 INTERNATIONAL ORGANIZATION FOR MIGRATION

17 Figure 4:: Importance of addressing population mobility and health of border communities within Ebola Recovery Strategies "The recovery strategy should be framed within the imperative of accelerating the development of remote border areas. This would reduce the vulnerabilities that expose the three countries to disasters that spiral out of control - Recovering from Ebola Crisis (UN-African Development Bank-World Bank-EU Plan). Cross border communities possess similar cultures, customs and social bonds and they address their day today concerns based on the structure which exist at the regional level. The response therefore to the Ebola outbreak would need to be a well-coordinated sub-regional approach.better sharing of high quality information and coordinated rapid response particularly in the border zones for the purpose of: i.)surveillance, ii.) Contact tracing iii.) Risk monitoring or controls - for example high risk groups, and iv.) Sharing of best practices - Mano Rive Union Regional Post Ebola Recovery Plan ENABLING COMMUNITY RESILIENCE AND RESTORING ESSENTIAL SERVICES This first pillar of the strategy is composed of several elements: Restoring the functionality of key government systems (including, but not limited to the Health systems) to effectively provide essential services to the public; Activities to Support Social Cohesion, Resilience Building, Disaster Risk Reduction; Counter-trafficking and Protection of Vulnerable Migrants; Technical Assistance for Humanitarian Border Management and Leveraging diaspora engagement to support post-ebola recovery RESTORING THE FUNCTIONALITY OF KEY GOVERNMENT SYSTEMS IOM will adopt an inter-sectoral approach (as articulated in the MCOF) in supporting the revitalization of primary health care facilities and other critical infrastructures and services as highlighted in the Ebola Recovery plans of affected governments. Such interventions will include infrastructural and operational interventions to ensure access to quality essential services, such as health, border posts, markets, schools, etc., to contribute to safety and socio economic development. Furthermore, the unpredictable devastating socio-economic impact highlighted the complex relationship between health system resilience and economic development. Greater still has been the impact on rural communities, particularly border communities, with pre-existing lower socio-economic outcomes, higher rates of poverty and lack of access to essential services. To date, the EVD response has focused on limiting transmission. However, increasing awareness of the emerging socio-economic crisis obliges international actors to support recovery efforts, addressing critical economic recovery needs. The epidemic has made this situation even worse, through loss of productivity and labour force, stigmatization, the loss of investment and a variety of other factors. The agricultural sector, upon which much of the rural region relies, has been particularly affected, as a result quarantines, fear, difficulties in reaching markets and a general deterioration in market conditions in the country. As a result, income generating activities supporting economic recovery and livelihoods of survivors, their families, the families of EVD victims, affected communities are urgently needed. Border closures which restricted the movement of people, goods and services and the suspension of weekly markets has severely disrupted key livelihood sources, including marketing of goods and agricultural commodities, particularly in communities which rely on cross-border trade. So far, the international response has primarily focused on preventing EVD transmission, while wider socioeconomic interventions have not been prioritized. IOM has been advocating for the need to link relief, recovery and development as a comprehensive approach in the response cycle, to ensure the continuity of humanitarian intervention and an effective, sustainable, transition to recovery and development. RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

18 Rehabilitation of basic infrastructure, support to local authorities to restart/improve their presence and capacity will be a key first step to recovery; to provide quick visible and tangible impact, providing a source of immediate income to the affected population, and facilitate resumption of service delivery, with a large effort on decentralization ACTIVITIES TO SUPPORT SOCIAL COHESION, RESILIENCE BUILDING, AND DISASTER RISK REDUCTION This set of activities will aim at providing assistance to governments and communities undergoing significant socioeconomic changes and whose social dynamics and safety nets have been disrupted. Following the EVD crisis IOM will work on re-establishing resilience in affected communities, empowering authorities and laying the foundations for sustainable development. Social Cohesion: IOM has been implementing comprehensive social cohesion and transition programmes worldwide in more than 50 countries. These initiatives are aimed at reducing and preventing the impacts of, and recovering from, the longer term consequences of crisis, in particular its effect on human mobility. These programmes through quickimpact, short-term job creation, provide livelihood opportunities and socio-economic initiatives, and contribute to increase the resilience of vulnerable communities. The EVD ultimately contributed to long term consequences and had a negative impact on development gains and governance structures in EVD-affected countries across the region, further contributing to state fragility and increasing the human and material cost of the EVD crisis and its response. Resilience Building: Recognition of individuals as agents of their own recovery is central, hence a focus on self-reliance and resilience building is increasingly perceived to be critical to the success of interventions. Resilience-building within IOM promotes people s role as active agents in the recovery process, thereby mitigating conditions conducive to aid dependency and negative coping strategies, and it sets the foundation for sustainable recovery and development. IOM will aim to increase the income of the communities heavily impacted by EVD while restoring key community assets, and further ensure that the communities have the skills and resources necessary to engage in sustainable livelihoods. This will be further realized by restoring small-scale trade and stimulate local production of staple foods to re-establish IOM s psychosocial team helps reintegrate Ebola survivors back into the community in Sinje, Liberia IOM INTERNATIONAL ORGANIZATION FOR MIGRATION

19 local systems; address emergency food shortages and strengthen community resilience. Moreover, due to the loss and stigma that Ebola has caused within affected communities, psychosocial activities will be a key element for building resilience. IOM is an active member of the Inter-Agency Standing Committee (IASC) Reference Group on Mental Health and Psychosocial Support in Emergency Settings, during which it has started up, chaired and/or co-chaired the Group in several emergencies.4 Since 2001, IOM has provided direct psychosocial support and capacity-building in more than 30 emergencies worldwide. Some notable examples include the psychosocial support given to migrants in transit areas and returnees in the recent crisis in Libya; support for the relocation of IDPs and victims of sexual- and gender-based violence after the earthquake in Haiti in 2010; assistance to the Government of Colombia in establishing a psychosocial strategy and for building the capacity of the reparation commission; and direct psychosocial assistance provided to IDPs and returnees in Lebanon following the 2006 crisis, to Iraqis displaced in Jordan and Lebanon, and currently to Syrian refugees in northern Lebanon. Disaster Risk Reduction: to reduce and mitigate the risk of displacement and increase the resilience of communities and local authorities to cope with future disasters in view of achieving sustainable development, by providing the necessary framework, methodology and tools to analyse the causal factors of disasters, reduce exposure to hazards, and lessen the vulnerability of people and livelihoods. IOM will work closely with the Economic Community of West African States (ECOWAS) to contribute to the implementation of their humanitarian action plan. Since the early 1990s, IOM has implemented Disaster Risk Reduction (DRR) in South-East Asia and the Pacific, Africa, and Latin America. A new generation of innovative programmes that integrate climate change adaptation has been developed. 10 In support of the implementation of the Hyogo Framework for Action and in accordance with IOM policy, the Organization s programming approach focuses on local and national authorities and communities through training, capacity building and simulation exercises (community- based approach), often as part of recovery efforts. Enabling Community Participation: community participation has been a critical factor in the success of Ebola interventions. 11, 12 A systematic focus on deepening community engagement in all aspects of the recovery phase is key, in order to foster greater ownership and sustainability, as well as provide outreach to hard-to-reach vulnerable populations. Community outreach and two-ways communication will be an integral step to achieving this, which embeds a participatory process that facilitates community interaction and promotes local ownership by engaging various members of a community to develop, implement and monitor projects. 13 This further includes working with national and international counterparts in efforts to rebuild, build resilience to shocks, and minimize risks of future crisis and providing the foundation for sustainable development COUNTER-TRAFFICKING AND PROTECTION OF VULNERABLE MIGRANTS To provide protection and assistance to vulnerable migrants, including victims of trafficking, exploitation or abuse and unaccompanied migrant children, during a crisis situation and in its aftermath. Crises may lead crisis-affected populations to undertake high-risk migration, creating opportunities for organized criminal groups, including traffickers and smugglers, as traditional support structures are often disrupted in a crisis, thus making the identification and protection of vulnerable migrants challenging. After the crisis ends, it often leaves behind a long tail of impoverishment and destitution that severely contributes to increase people s vulnerability. This is the case of those children who lost because of the EVD their parents or the family s bread-winner and have now to struggle to have access to resources and basic services. In this delicate phase, it is paramount to ensure a proper protection system and avoid exploitative mechanisms. Since 1994, IOM has worked to counter trafficking in persons and migrant exploitation, such as in crisis-affected countries, like Libya (2011), Haiti (2010) and Indonesia (2004). In cooperation with governments, relevant United 10 IOM is a member of the Strategic Advisory Group (SAG) of the Global Cluster on Early Recovery, through which it engages on key policy decisions and strategy development on Early Recovery issues within the IASC framework. IOM staff have undergone UNDP-sponsored training on the roles and functions of Early Recovery Advisors, and are on a roster for deployment as part of system-wide crisis response and recovery. Within the Cluster, IOM also participates actively in the Technical Working Group on Durable Solutions which is dedicated to refining and operationalizing the UN Secretary General s Framework on Durable Solutions. IOM staff have deployed to assist in the development of inter-agency country strategies for Durable Solutions. 11 Shrivastava, S. R., Shrivastava, P. S., & Ramasamy, J. (2015). Public health strategies to ensure optimal community participation in the Ebola outbreak in West-Africa. Journal of Research in Medical Sciences, 20(3). 12 Abramowitz SA, McLean KE, McKune SL, Bardosh KL, Fallah M, et al. (2015) Correction: Community-Centered Responses to Ebola in Urban Liberia: The View from Below. PLoS Negl Trop Dis 9(5): e doi: /journal.pntd As part of its policy development and institutional strengthening efforts, IOM is also finalizing its own framework guidance on resolving situations of displacement. The development of this framework has involved key stakeholders in the Working Group on Durable Solutions, and will contribute to IOM s partnership with the Early Recovery and Protection Clusters, as well as with the Transitional Solutions Initiative. RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

20 Nations agencies and non-governmental organizations (NGOs), the Organization has helped to protect through direct assistance measures more than 25,000 trafficked persons, approximately one third of whom were children. IOM maintains a global database to facilitate its case management process. The global database contains extensive primary data on individual trafficked persons it has assisted and is increasingly valued as a unique research tool. In addition, IOM works to prevent trafficking in persons and migrant exploitation through targeted information, education and communication initiatives. IOM also builds the capacities of governments and civil society actors to address the challenges posed by human trafficking by creating training opportunities for government officials and NGOs and by providing expert technical support for the development of counter-trafficking policies and procedures TECHNICAL ASSISTANCE FOR HUMANITARIAN BORDER MANAGEMENT (HBM) This set of activities aims to support States in building and maintaining operational capacity. As well, in times of crisis robust immigration and border management programmes supported by appropriate policies, laws, procedures and information systems facilitate orderly and safe movement of people following emergencies. The EVD crisis has highlighted weaknesses in border management with regards particularly to contact tracing, surveillance and application of IHR. IOM has trained tens of thousands of immigration and border management official around the world on such topics as human rights and refugee law, trafficking in persons and freedom of movement. Moreover, IOM has developed the Migration Information and Data Analysis System (MIDAS), which provides States with a system to better monitor border movements and shape migration policies. Notable humanitarian border management projects implemented by IOM include capacity-building in Iraq, which focused on promoting solutions to the protracted Iraqi displacement, and in Somalia, where the project aimed to contribute to enhanced border and immigration management for safe and orderly travel within and through Somalia, including its territorial waters. In relation to the Libyan crisis, IOM helped the authorities in neighbouring Tunisia to maintain their borders open by aiding them in the identification of those fleeing the crisis and making appropriate referrals. IOM takes a comprehensive approach to humanitarian border management within the wider context of managing migration to support governments in integrating the humanitarian border management measures into broader migration governance framework LEVERAGING DIASPORA ENGAGEMENT TO SUPPORT POST-EBOLA RECONSTRUCTION EFFORTS EVD has resulted in a tremendous depletion of human resources in key sectors, such as education and health. In an effort to ensure sustainable reconstruction in the countries affected by the disease it is paramount that appropriate resources are allocated to reproduce the skills and knowledge needed by individual countries. IOM will work with national authorities to map out human resources needs in key sectors (these will not be limited to health and education but others, such as tourism, can also be explored) and to establish programmes aimed at attracting qualified members of the diaspora to: 1) Temporary return to their origin country to fill in vacant positions; 2) Deliver training of trainers/mentoring to ensure that skills and knowledge are sustainably transferred to the in local population. Furthermore, IOM will also provide targeted platforms, such as crowd-funding websites for diaspora communities to be able to financially contribute to support post Ebola programmes already in place, including to combat stigmatization at the work place, to foster community reintegration efforts and to support single parents and unemployed youth to establish small businesses, among others. IOM will work in partnerships with all relevant stakeholders, including nonstate actors and EVD survivors associations, to set up this mechanism. IOM has also undertaken a comprehensive mapping of Diaspora health professionals in 2014 that live in countries, such as Germany, USA, UK and Canada who are willing to return on short and long-term basis to meaningfully support health systems recovery. This may include technical training, professional mentoring programs to direct service delivery through clinical work at peripheral health institutions (see Annexure 2). The training and capacity building components may be modelled in alignment with IOM s Africa Capacity Building Centre located in Moshi, Tanzania (see Annexure 3). 16 INTERNATIONAL ORGANIZATION FOR MIGRATION

21 FACILITATING LABOUR MOBILITY FOR ENHANCED RESILIENCE Knowledge/skills transfer and financial support, through diaspora engagement alone, will not solve the big human resource/economic gap, left by EVD, and will not address all the labour market challenges that EVD-affected countries are facing. Unemployment rates, especially among the youth, are extremely high. In some instances, an increase in internal migration has been observed among EVD survivors, who have been stigmatized and, hence, left their usual places of residence, and family members, dependent on breadwinners who passed away from EVD, that had to leave the housing allocated to them by private companies. A clear understanding of the labour market gaps and human resources/skills existing are key to establish programmes that contribute to matching labour offer and demand within and across affected countries, hence providing additional economic opportunities. IOM proposes to conduct a thorough employment mapping in all affected countries, in close coordination with national authorities and the private sector, to identify the job opportunities available locally and to highlight the gaps and the skills that need to be created level to start rebuilding the economy. IOM will contribute to the development of capacity through supporting international scholarships opportunities for healthcare staff and offer targeted vocational training programs can be developed in partnership with key stakeholders and the most vulnerable (i.e. unemployed survivors or victims family members) will be targeted, through an internal migration tracing exercise. Furthermore, within the overall goal to contribute to repopulate in-country skills and knowledge gap, IOM will build on the ECOWAS free movement of persons protocols and it will promote the establish students exchange programmes between EVD countries and other ECOWAS countries (i.e. Ghana). These exchanges will contribute to further strengthen the capacities of senior students in selected fields and to combat EVD stigmatization while promoting social cohesion among countries in West Africa. Develop labour market relevant training opportunities and job placement programmes to support employment of most vulnerable population internally displaced by the disease. Migration Policy and Legislation Support: to support States, individually and collectively, in building the policy, as well as the administrative and legislative, structures and capacities that will enable them to manage migration during crises effectively and humanely and fulfil their responsibilities in identifying, assisting and protecting vulnerable mobile populations affected by crisis. At their request, IOM has assisted governments in developing policy, law, research and mechanisms for cooperation on migration issues related to crises. For example, IOM has facilitated exchanges of best practices and is supporting the development of standard operating procedures (SOPs) on emergencies affecting migrant workers among governments of the Colombo Process, a regional consultative process that focuses on labour migration from Asia. IOM also routinely supports States in formulating policy and building capacity to manage migration during crises. A notable example is the training IOM provided to 49 staff of the Parliament and various ministries of the Government of Afghanistan in 2011 and 2012, building national capacity in migration management, including policy and legislation, and focusing on labour migration, international cooperation on migration and border management HEALTH, BORDER AND MOBILITY MANAGEMENT (HBMM) IOM s approach to responding to disease outbreaks and preparing for future health threats is particularly anchored upon human mobility, notably through the Health, Borders and Mobility Management (HBMM) framework. The summary of the components within the HBMM framework are shown in Annexure 1. HBMM has the ultimate goal of improving prevention, detection and response to the spread of infectious diseases and other health threats along the mobility continuum (at origin, transit, destination and return points), and its spaces of vulnerability with particular focus on border areas. This goal directly supports the Global Health Security Agenda, described in Section At the core of HBMM is the understanding that mobility is a continuum that extends beyond the physical or regulated border areas, such as the official Points of Entry (or PoEs, as articulated within IHR, 2005), to include pathways and spaces of vulnerability. Grounded on this understanding, the scope of HBMM ranges from collection and analysis of information on mobility patterns, to disease surveillance and health threat response mechanisms at spaces of vulnerability along mobility pathways. HBMM, therefore, ultimately contributes to health system strengthening that is sensitive to mobility dynamics, notably at the primary health care level THE MOBILITY CONTINUUM: STAGES OF MOBILITY AND SPACES OF VULNERABILITY 14 Mobility takes place along a continuum, which encompasses points of origin and destination, and the multiple pathways in between. This mobility continuum represented in the below schematic diagram depicts the key population 14 Space of Vulnerability: there are two elements to the definition of space of vulnerability. First, refers to an assessment of concentration of people within a geo-spatial loci, and second relates to movement patterns/dynamics of people within this space. The more dense the concentration of population, the more complex the movement pattern, the greater the potential risks for spread of pathogens and the need for preventative and promotive interventions. Points of entry and exist (both formal and informal) and other border crossing/ landing points are components of this RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

22 movements, which takes into account routes, the transit and congregation points along the way, and the connection between these. This graphical layout attempts to capture the space of vulnerability. A person may choose to travel using one or more of these routes: land, air and water to their intended destination, as illustrated in Figure 5 within the green pathways. Figure 5:: The Mobility Continuum DESTINATION HEALTH EVENT DETECTED HEALTH EVENT DETECTED HEALTH EVENT DETECTED HEALTH EVENT DETECTED HEALTH EVENT DETECTED HEALTH EVENT DETECTED BORDER HEALTH EVENT DETECTED Coordination & Information Exchange TARGET/LOCATION Migrants & Mobile Populations (MMP) at Origin (pre-departure) & Destination (post-arrival) Travel by LandVehicle: train/bus/truck/car/motorcycle Footpath/Informal Ground Crossing Travel by Air Travel by Sea MMP Transit and Congregation Hubs Traditional Healers Health Facilities Marketplaces Transit Depots Temporary Residence Ferry/Fishing Wharfs Places of Worship Schools Workplaces (Mining/Timber/Agriculture/Fisheries) MMP at Transit and Congregation Hubs Point of Entry (Ground,Airport & Seaport) MMP at Point of Entry Health Screening Immigration, Law Enforcement, Customs & Quarantine Ground Crossing ORIGIN HEALTH EVENT DETECTED HEALTH EVENT DETECTED Airport Seaport/Wharf Health Event Detected: initiate Public Health Response and refer migrant to Health Service Public Health Response Emergency Operations Center (EOC) Referral Health Service Coordination & Information Exchange Border Community National Government In departing from origin or specific place along a route, Migrants and Mobile Populations (MMPs) may pass through important transit and congregation points before reaching their final destinations. These points may include transportation/transit hubs, temporary domiciles, market places, ferry/fisherman landings, airports and workplaces. Each of these settings may possess specific health vulnerabilities, depending on the scale of mobility flows, interactions between MMPs and host communities, and potential occurrence of a public health threat, such as communicable disease outbreaks. These transit and congregation points constitute spaces of vulnerability. At these spaces of vulnerability, mobility pattern mapping is an important activity to guide public health interventions, and serve as an evidenceinformed tool for installing health screening posts and referral mechanisms in the event of a rapidly progressing disease outbreaks (or occurrence of other types of health threats). Public health responses may be initiated through close coordination between transit and congregation points, Emergency Operation Centres (EOCs) and referral health services, activated whenever a health event is detected. Cross-border MMPs will subsequently cross international borders, either by land, air or water. At these international border crossing points, health screening and immigration, custom and quarantine procedures are applied, from where population density continuum. Public health risks are heightened within this mobility continuum, such as at market places where vendors and buyers congregate from various origins on both sides of a border, or mines, agriculture fields, farms and other labour-dense workplaces where labour migrants can be found in large numbers. These spaces of vulnerability are frequently neglected or not understood by public health interventionists, and therefore lack the basic structure and mechanism for adequate prevention, detection and control of health threats. PoEs and other border crossing/ landing points are only components of this continuum. Understanding mobility patterns is essential to identifying these various spaces of vulnerability, and in order to do so a comprehensive approach to collecting mobility information is necessary. Ultimately, integrating evidence generated from mobility and movement patterns with epidemiological data provides the platform for more robust and effective public health interventions, communicable disease response and border health interventions. Communities, notably those residing along borders, also play a key role in efforts put forward to prevent, detect and respond to public health emergencies. Well-managed borders that are sensitive to the health needs of mobile populations can facilitate health services on both sides of the border, while ensuring case management and broader public health security measures. 18 INTERNATIONAL ORGANIZATION FOR MIGRATION

23 public health response and health referrals can also be activated. Moreover, along international land borders are human settlements, the border communities, many of which are engaged in informal and unsupervised cross-border movement as part of their daily lives. In these border communities, public health measures also need to be put in place to prevent, detect and respond to health threats THE FOUR PILLARS OF THE HBMM FRAMEWORK The operationalization of HBMM is guided by the four pillars of the World Health Assembly Resolution on migrants health, 15 and adapted to the border, health and mobility perspective: Pillar 1: Policies and legal framework on health, mobility and border management Pillar 2: Operational research, evidence, data gathering and sharing Pillar 3: Enhanced capacity of health systems and border management services Pillar 4: Inter-sectoral and multi-country partnerships and networks These four pillars are further articulated through ten core activities (see Figure 6). Although some of these core activities may seem to be and can be implemented independently, they are ultimately interrelated, mutually supportive and essential in realizing the goal of HBMM. Within EVD recovery efforts, IOM needs to embrace the totality of HBMM, and work towards its full operationalization. Although the implementation of all ten core activities may not happen simultaneously, the comprehensive HBMM mindset needs to be built, mainstreamed, and sustained to ensure the realization of all the components of HBMM. Moreover, the operationalization of HBMM will be influenced by the stage of infectious disease outbreak/ epidemic, or the occurrence of other health threats. An epidemic curve provides a graphical display of cases in an outbreak plotted over time (see Figure 7). As noted in Annexure 3, these stages are arbitrarily defined for purposes of tailoring intervention strategies, where in actual fact there are multiple classes of epidemic curves that vary according to epidemiological gradients and pathogenicity. Official national disease surveillance reports and international epidemiological alert system, such as those from WHO should always guide staging of the outbreak UNPACKING THE 10 COMPONENTS OF THE HBMM FRAMEWORK The following sections describe the 4 pillars and 10 core activities of the HBMM framework. Figure 4 maps these ten core activities against the four pillars of the HBMM Framework within the mobility continuum, with a focus on known spaces of vulnerability. Both the narrative and Figure 4 will serve to guide IOM missions in implementing HBMM programme. Figure 6:: Four Pillars of the HBMM Framework PILLARS POLICIESAND LEGAL FRAMEWORK ON HEALTH, BORDER AND MOBILITY MANAGEMENT OPERATIONAL RESEARCH, EVIDENCE, DATA GATHERING AND SHARING ENHANCED CAPACITY OF HEALTH SYSTEMS AND BORDER MANAGEMENT SERVICES INTER-SECTORAL AND MULTI- COUNTRY PARTNERSHIPS AND NETWORKS ACTIVITIES Needs Assessment, Operational Research, and Data Collection Surveillance/CEBS/IDSR Data Analysis and Risk Mapping Data Dissemination and Reporting SOP Development (IPC, Case Management, and Migration Management), Training Manuals and Curriculum, Simulation of PHEIC Events, and Training Implementation Health Screening and Referral System Health Management and Public Health Response Provision of Infrastructure and Supplies Social Mobilization, Population Awareness, and Behaviour Change Coordination and Dialogues Figure 7:: An epidemic curve of a common source outbreak 15 World Health Organization. (2010). Health of migrants: the way forward: report of a global consultation, Madrid, Spain, 3-5 March RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

24 PILLAR 1: POLICIES AND LEGAL FRAMEWORK ON HEALTH, MOBILITY AND BORDER MANAGEMENT Policies and legal framework (Pillar 1) over-arches the three other pillars of HBMM, in the view that all aspects of HBMM operationalization have definitive policy and legal implications. IOM mainstreams advocacy on migrants rights and better management of migration challenges in all of its programming, and therefore supports the implementation of Pillar 1. Additionally, Pillar 1 is directly related with the fifth Strategy for Ebola Recovery on addressing structural factors of systems and governance, more specifically within the spheres of migration and health sector. PILLAR 2: OPERATIONAL RESEARCH, EVIDENCE, DATA GATHERING AND SHARING Despite recognition of the direct contribution of human mobility to the spread of communicable diseases, empirical evidence supporting this correlation is scarce. Moreover, knowledge of human mobility dynamics is so far limited, notably on the behavioural aspects of those engaging in mobility themselves. Four core activities fall under Pillar 2: Activity 1: Needs assessment, operational research and data collection Activity 2: Surveillance / CEBS / IDSR Activity 3: Data analysis and risk mapping Activity 4: Data dissemination and reporting Activity 1: Needs assessment, operational research and data collection Within HBMM, the first step of evidence building is data collection, which is the foundation of Activity 1. It comprises various methods and modalities used to: 1) collect information on mobility patterns, migration intentions, availability and quality of border health legal frameworks; and 2) assess national and cross-border capacities (IHR, health system, preparedness, contingency and emergency response plans). These includes structure needs assessment, operational research and other data collection methods, such as mobility-related surveys and flow monitoring. Subsequently, this core activity encompasses the development and strengthening of health and mobility related IOM and community members work together to identify and prioritize mobility pathways and places most vulnerable to public health risks, during a Participatory Mapping exercise in Kambia, Sierra Leone IOM INTERNATIONAL ORGANIZATION FOR MIGRATION

25 information systems. During periods of high disease transmission (Stage 1 on epidemic curve on Figure 5), surge capacity for data collection on mobility patterns will serve to guide public health response addressing specific health vulnerabilities resulting from human mobility. In such scenarios, data collection will be implemented together with health services under Pillar 3, notably under health screening and referral system (Activity 6). Scope of implementation: this core activity can be implemented throughout the mobility continuum with a focus on spaces of vulnerability, such as congregation and transit hubs and landing and crossing points. During periods of high disease transmission, this activity will be done conjointly with Activity 6. Activity 2: Surveillance / CEBS / IDSR Strengthening disease surveillance capacities was and remains critical in bringing down the Ebola epidemic and maintaining zero infections. These capacities will also determine how future outbreaks will be detected and responded to. Cross-border disease reporting mechanisms have particularly been the focus of the EVD response. IOM has taken a proactive role in linking mobility information to surveillance data and vice versa, and continues to advocate for the inclusion of mobility information into formal surveillance systems, either as part of Community Event Based Surveillance (CEBS), or the Integrated Disease Surveillance and Response (IDSR) mechanisms, both of which IOM contributes to within current and future programming. Within the scope of EVD recovery and beyond, capitalizing on its active role in cross-border health management throughout the EVD response, IOM needs to strategically contribute to the development, improvement and formalization of national surveillance protocols, including CEBS and IDSR. Scope of implementation: IOM is particularly well-positioned to influence and strengthen surveillance mechanisms at border communities, and migrant-dense areas. Activity 3: Data analysis and risk mapping Disease surveillance and mobility pattern mapping will only reach its intended outcome within HBMM if information Through participatory mapping, busy markets, like this one in Tintafor, Sierra Leone, are identified as priority locations for HBMM interventions, due to accentuated health vulnerabilities, as a result of human mobility IOM 2015 Places where international travellers, fishermen, and local populations mix, such as Konakridie Wharf in Sierra Leone, are also identified as more vulnerable to the spread of infectious diseases, due to human mobility IOM 2015 RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

26 collected from both initiatives are jointly analysed. In order to identify, locate and map spaces of vulnerability within mobility continuum and assess their associated public health risks, data analysis of both epidemiological and mobility information needs to be done conjointly and focus on the correlation between the two. The result of such analysis will be a better understanding of where health risks may be accentuated as a direct consequence of human mobility, and where health system capacities are still lacking. Scope of implementation: This activity is implemented in all locations where Activity 1 and 2 are implemented. Activity 4: Data dissemination and reporting Clear strategies for reporting and disseminating analysed information on health and mobility needs to be clearly defined, including reporting mechanisms and dissemination channels for the purpose of directing public health interventions, as well as advocacy. Scope of implementation: This activity is implemented in all locations where Activity 1, 2 and 3 are implemented, as well as at national, regional and international fora. PILLAR 3: ENHANCED CAPACITY OF HEALTH SYSTEMS AND BORDER MANAGEMENT SERVICES Information on health and mobility needs to be subsequently translated into better health and border management services. Pillar 3 encompasses the different components needed to improve delivery of these services, which are articulated in the following four core activities: Activity 5: SOP development (IPC, case management, and migration management), training manuals/ curriculum, simulation for PHEIC events (see Figure 8), and training implementation Activity 6: Health screening and referral system Activity 7: Health management and public health response Activity 8: Provision of infrastructure and supplies Activity 5: SOP development (IPC, case management, and migration management), training manuals/ curriculum, simulation for PHEIC events, and training implementation Figure 8:: Disaster management skills of local authorities are evaluated and reinforced, through simulation exercises conducted by IOM at Lungi Airport in Sierra Leone IOM 2015 At the foundation of quality service delivery are sound procedures and trained providers. This core activity encompasses initiatives ranging from the development of training manuals, curricula and SOPs, up to the implementation of such trainings, including through desktop and field simulation of response to PHEIC events. Scope of implementation: This activity is normally implemented at national levels, but training may be expanded and adapted to local administrative levels, in which case IOM is well-positioned at border areas. 22 INTERNATIONAL ORGANIZATION FOR MIGRATION

27 UN Secretary General Ban Ki-moon undergoes health screening at Lungi Airport in Sierra Leone IOM 2014 Activity 6: Health screening and referral system Capacities for health screening and referral are built through Activity 5. In the event of a health threat, a health screening mechanism may be put in place at vulnerable spaces where transmission risks and spread of health threats are highest, taking into consideration mobility dynamics. Screening procedures need to be adapted to the specific characteristics of individual disease and health threat, and linked with a competent referral system, which is connected to Ministries of Health structures and Emergency Operations Centres (EOCs) or other coordination mechanisms. Both health screening and referral services can be directly provided by IOM, or in support to the Ministries of Health where IOM only covers certain technical/operational gaps. Regardless of the scenario, these services need to be provided with the vision of strengthening health systems, sustainability and building the capacity of Ministries of Health. Furthermore, health screening posts can be serve as a location for surge data collection on mobility, notably flow monitoring, which can in turn strengthen the response to health threats. Within its EVD response, IOM utilized a network of flow monitoring points set up in tandem with health screening posts in transit and congregation hubs along mobility pathways and in cross-border areas. Additionally, IOM supported the implementation of early detection and referral of cases at PoEs, through the implementation of primary and secondary screenings. Scope of implementation: the implementation of Activity 6 is tailored according to the phase of disease transmission within an epidemic, and health threat occurrence. In the context of high disease transmission with a high burden of cases, a full range of interventions, including scale up of flow monitoring are undertaken conjointly with health screening procedures. Activity 7: Health management and public health response Clinical case management and public health response are critical services that follow health screening and referral. Both are to be guided by formal protocols, such as those developed by WHO and Ministries of Health. This core activity represents a critical function of health systems. During the acute phase of its EVD response, IOM intervened directly in both areas by setting up and operating three ETUs Liberia and supporting the coordination and response mechanisms of the Guinean EOC network. Within EVD recovery efforts, these service delivery capacities need to be transferred to the national health systems through capacity building (Activity 5). Scope of implementation: the implementation of Activity 7 is pronounced during stages of intensive disease transmission. IOM is well-positioned to intervene and provide direct services and operations anywhere where gaps RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

28 are present, but its unique strength will once again be at borders and migrant dense areas. Activity 8: Provision of infrastructure and supplies Underlining the quality of services provided through Activity 6 and 7 is the issue of infrastructure and supply chain. IOM is well-known for its logistics and field operational capacity which are the centre of implementation of Activity 8. Throughout the EVD response, IOM procured, distributed and administered IPC materials in the three most affected countries and three of their neighbours at ETUs, health screening posts and EOCs. IOM also established the communication system for its supported EOCs and at all flow monitoring points. Within the recovery phase, IOM is well-position to support supply management systems and contingency stock-piling, as well as strengthen communication systems in all affected countries and beyond. Scope of implementation: this core capacity can be implemented at locations where all other core activities are implemented at vulnerable spaces where transmission risks are heightened, and at primary health care structures, notably at border and migrant dense areas. PILLAR 4: INTER-SECTORAL AND MULTI-COUNTRY PARTNERSHIPS AND NETWORKS HBMM requires multi-sectoral and multidisciplinary partnerships to: 1) engage target populations and communities in adopting healthy behaviours, and 2) ensure understanding and buy-in from partners outside of the health sector, and partners across the border. The following two core activities are part of Pillar 4: Activity 9: Social mobilization, population awareness and behaviour change; and Activity 10: Coordination and dialogue. Activity 9: Social mobilization, population awareness and behaviour change This core activity targets migrants, mobile population as well as host communities, notably those residing along borders and in migrant-dense areas. Within its EVD response, IOM carried out large social mobilization initiatives aimed at building community participation in curbing the spread of Ebola, including through adoption of safe burial practices, safe meal preparation practices, notification of suspect cases, contact tracing, and self-quarantine. Within the recovery phase, IOM has started directing its social mobilization and awareness raising efforts to build community participation in CEBS, and monitoring mobility in their surroundings. Scope of implementation: throughout the mobility continuum from origin to destination, at host communities, notably at border and migrant dense areas, in conjunction with the implementation of Activity 1 and 2. Activity 10: Coordination and dialogue To effectively enable disease prevention, detection and control, in addition to health transportation authorities, multi-sectoral interventions involving border management authorities, law enforcement, military, trade, and commercial actors are needed. IOM has already facilitated such coordination and dialogue within countries and cross-border, in conjunction with mobility mapping efforts, CEBS, and health system support. Within the recovery phase, such initiatives need to be further expanded to strengthen preparedness capacities in the event of another epidemic or health threat. Scope of implementation: throughout the mobility continuum from origin to destination, at local, national and regional levels CROSS-CUTTING PILLAR: TRAINING AND CAPACITY BUILDING IOM's recovery strategy for enhancing training and capacities for mobility and health is a three-pronged approach that will aim at providing: (1) targeted training of relevant officials and partners; (2) support Regional Governance structures; and (3) establish a Regional Training Academy/Centre for Population Mobility and Health. 1) Training and empowering relevant government actors to enhance their skills and capacities within the domains of health and migration management in the context of mobility within cross-border contexts. IOM adopts the Safe and Quality Services (SQS) approach for health systems strengthening for EVD, namely IPC standard precautions; disease surveillance, fundamentals for clinical emergency management, and psychosocial support. Training components within the health domain: Utilizing the tools developed by the joint IOM-CDC-WHO working group which emphasizes: a) IPC practice (at border entry/exist points, Primary health care level, hospital level) 24 INTERNATIONAL ORGANIZATION FOR MIGRATION

29 b) Community Event Based Surveillance, preparedness and response (CEBS) Preparedness and response of Public Health Events of International Concern (PHEIC) events at border areas Information management practices to enable health and border management practices Communicating public health risk in context of border communities Psychosocial and mental health Information Technology and Computer skills training Cultural and language specific IEC material for health promotion on EVD for communities, especially those migrant and mobile populations that are non-citizens Undertaking applied research to inform programs and training, such as understanding health-seeking behaviours of various migrant and mobile population groups Training components within the migration management domain: Enhancing effective migrant protection and border management policies and practices Information Technology and Computer skills training Skills in undertaking Participatory Risk Assessment and Health Impact Assessments (HIA) of cross-border communities/mobile populations Training components in disaster risk management: It will be critical for local authorities to strengthen their Disaster Management capacities via trainings and simulation exercises, in order to better tackle their response challenges. 2) Supporting capacity building of Regional Governance structures and Regional Coordination Mechanisms 16 to mount effective, multi-sectoral, cross-border interventions targeting migrants and mobile populations. For instance, in partnership with MRU regional cooperative, IOM will seek to implement a cross-border project through the participation of mining and transport sectors to build a robust health promotion and disease prevention program along a mobility continuum. 3) Establishment of a Regional Training Academy/Centre Objectives of the Regional Training Centre/Academy will be to: Support West African states commitment to strengthen evidence informed policies, legal frameworks and management capacities to address health vulnerabilities of migrant and mobile populations, with an emphasis on cross-border movements. Enhance HBMM to promote good migration governance both on a national and regional scale. Avail technical expertise to requesting West African states to identify and respond to key health challenges along the mobility continuum. Develop and deliver on-and off-site mobility related health and migration management training programs. Undertake applied research in order to inform policy and practice for the region along spaces of vulnerability along various mobility corridors. Develop a return of qualified nationals to identify available human resources in the Sierra Leonean healthcare diaspora to support health sector capacity building. In 2014, IOM had also undertaken a comprehensive mapping of diaspora health professionals that live in countries, such as Germany, USA, UK and Canada, who are willing to return on short and long-term basis to meaningfully support health systems recovery. This support may include technical training, professional mentoring programs to direct service delivery through clinical work at peripheral health institutions (see Annexure 2). The training and capacity building components may be modelled in alignment with IOM s Africa Capacity Building Centre, located in Moshi, Tanzania (see Annexure 3). 16 Regional Coordination Mechanisms: Mano River Union Cooperative, African Union and Economic Community of West African States (ECOWAS) RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

30 TABLES 26 INTERNATIONAL ORGANIZATION FOR MIGRATION

31 Table 1:: HBMM Scope of Activities in Relation to Locations within the Mobility Continuum OVER ARCHING PILLAR PILLAR CORE ACTIVITY B. Operational research, evidence, data gathering and sharing C. Enhanced capacity of health systems and border management services 1. Needs assessment, operational research and data collection 2. Surveillance / CEBS / IDSR Place of origin Migration intention, disease profiling Regular surveillance ACTIVITIES AT DIFFERENT LOCATIONS WITHIN THE MOBILITY CONTINUUM Congregation hubs / flow monitoring points Mobility surveys, flow monitoring, health services capacity assessment Linkage of mobility information into CEBS / IDSR International land borders, airports and seaports Flow monitoring, mobility assessment, IHR core capacity assessment at PoE Linkage of mobility information into CEBS / IDSR EOCs Preparedness and response capacity assessment Referral health services Preparedness and response capacity assessment Border cities, towns and villages Mobility surveys, flow monitoring, health services capacity assessment Place of destination Disease profiling IDSR IDSR CEBS Regular surveillance 3. Data analysis and risk mapping 4. Data dissemination and reporting 5. SOP development (IPC, case management, migration management), training manuals/curriculum, simulation for PHEIC events, training implementation 6. Health screening and referral system 7. Health management and public health response 8. Provision of infrastructure and supplies 9. Social mobilization, population awareness and behaviour change 10. Coordination and dialogues Migration management, IPC, primary health care Travel health assessment Primary health care IPC, CEBS, health screening and referral during periods of high disease transmission Embedded during periods of high disease transmission Response activation IPC, health screening and referral during periods of high disease transmission Embedded during periods of high disease transmission Response activation IPCs, emergency response plan and SOPs, contingency plan Response activation Response team deployment IPC, case management SOPs, emergency response plan and SOPs, mass casualty management SOPs Triage, ambulance operation Case management IPC, CEBS Migration management, IPC, primary health care for migrants Embedded during periods of high disease transmission Response activation Health screening for migrants Primary health care A. Policies and legal framework on health, mobility and border management D. Inter-sectoral and multi-country partnerships and networks Health behaviour change, safe migration Dialogue with places of destination Health behaviour change, safe migration, CEBS Coordination with MOH, EOCs, law enforcement authorities Health behaviour change, safe migration Coordination with Port Health and MOH, Customs / Immigration / Quarantine Information campaign, IEC development Coordination with health facility Information campaign, IEC development Coordination with EOC Health behaviour change, safe migration, CEBS Coordination with MOH, EOC, law enforcement authorities Health behaviour change, safe migration Dialogue with places of origin RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

32 ANNEXURE 28 INTERNATIONAL ORGANIZATION FOR MIGRATION

33 ANNEX 1. MEANINGFUL ENGAGEMENT OF DIASPORA PROFESSIONALS IN CONTRIBUTING TO RECOVERY EFFORTS Under its Migration for Development in Africa (MIDA) programme, which helps to mobilize African diaspora skills for the benefit of Africa s development, and in particular its MIDA Health initiative, the IOM seeks to address the challenges produced by the migration of health-care workers through the transfer of diaspora knowledge and skills to the benefit of their home countries health sector. IOM undertook three mapping surveys in the United Kingdom, United States and Canada, and Germany between September 2012 and October The surveys aimed to identify available human resources in the Sierra Leonean health-care diaspora to support Sierra Leone s health sector, whether in training or other health institutions, by way of temporary return to Sierra Leone. IOM intends to develop a national strategy to facilitate short-term placements of Sierra Leonean health professionals in the diaspora in selected health facilities in Sierra Leone. This strategy will support the implementation of the National Health Sector Strategic Plan (NHSSP ), Sierra Leone s national response to improving its health sector. Among the several issues identified in the NHSSP , the shortage of skilled staff and mal-distribution of existing staff remains a challenge to the appropriate delivery of Sierra Leone s basic package of essential health services. IOM Sierra Leone is the leading implementing agency for this initiative. At the request of the Office of Diaspora Affairs, IOM is supporting the Ministry of Health and Sanitation (MoHS) by conducting a comprehensive situational assessment of migration health-related challenges and service gaps in order to develop interventions for better access to health care. Sierra Leonean diaspora health-care professionals are well aware of the poor state of the health system in their home country. In many cases, the health professionals interventions in Sierra Leone s health sector occurred after witnessing the precarious state of health facilities during their trips to the country. Diaspora health-care professionals were genuinely willing to improve the well-being of Sierra Leoneans, especially those directly affected by the civil war, and develop the infrastructure of the health facilities. There was also a strong desire to educate the population about basic health measures to prevent diseases, and to provide training for health professionals in Sierra Leone. Many diaspora health-care professionals are already individually or collectively involved in contributing to the development of Sierra Leone s health sector. They associate themselves in groups and organize fundraising events to develop health missions to Sierra Leone, some travelling to Sierra Leone at least once a year. In the German study, approximately 60 per cent of respondents had contributed skills in various ways, for example through shortterm clinical assistance in hospitals and donations of medication, clothes and medical equipment to facilities in their homeland. The diaspora health professionals expressed a strong desire to contribute to the development of the health-care delivery system in Sierra Leone. They consider that to guarantee a successful diaspora engagement programme, the Government needs to act as a key facilitator to ensure that Sierra Leonean professionals and institutions recognize and support diaspora initiatives. 29 RECOVERING FROM THE EBOLA CRISIS A STRATEGIC FRAMEWORK FOR ACTION

34 ANNEX 2. IOM AFRICAN CAPACITY BUILDING CENTRE As a result of intensive discussion and design by the Africa Group of the International Organization for Migration, the African Capacity Building Centre (ACBC) has been established in Moshi, Tanzania (2009). The ACBC is located at the Tanzania Regional Immigration Training Academy (TRITA), which is a fully operational and equipped training facility that has the support of the East African Community (Burundi, Kenya, Rwanda, Tanzania and Uganda) and the EAC Secretariat. African states seek the ACBC s support to assist them in establishing sound migration policies, robust administrative and technical structures, as well as the all-important human resource base necessary to tackle diverse migration issues. Over the last five years, the ACBC s team of experts have responded to an increasingly wide range of requests from African states to build their countries' capacities and shape innovative solutions in migration management. As of July 2013, the ACBC has trained over 3,100 immigration and border management officials from 47 different African states. African states are eligible to receive operational, technical and administrative support from the centre of excellence. IOM Member States, requesting support, are encouraged to contact the Chief of Mission at the nearest IOM Country Office. The ACBC, in coordination with the Chief of Mission at the respective Country Office, will identify and assess available solutions to be further discussed with the requesting State. In line with the IOM Constitution, IOM Mission Statement and the IOM Twelve Point Strategy, the objectives of the centre are: Assist the Beneficiary States in developing and implementing comprehensive border and migration management policies, strategies and legal frameworks; Support the Beneficiary States migration, administrative and operational frameworks, including national training capacities and infrastructure; Enhance border management information systems through advanced border data collection, sharing and analysis; Promote understanding of and responses to migration challenges and opportunities through program research and development; Encourage joint action through advocacy, partnerships and cross-border cooperation. During its mere two years of existence, the ACBC Team has trained over 1,400 persons, spent more than 300 days in the field to support countries and IOM missions, and has assisted with the implementation of projects in 34 African countries and regional bodies. These encouraging results exhort the ACBC to carry on this challenging, yet rewarding, path to further support the smooth and humane management of migration on the African continent, working hand-in-hand with its national and regional partners. In order to achieve these objectives, the ACBC provides technical expertise on all topics related to migration management. Through assessments, training, technical assistance, research and project development, the ACBC assists African governments and IOM missions by offering support in the areas of integrated border management, establishing, delivering and refining immigration training curricula, identity management, border management information systems, trafficking in persons and other related topics. The TRITA offers computer training labs, training rooms and residential accommodation for up to 60 participants. For more information, visit: ACBC delivers capacity-building training, focusing on, among other topics, counter-trafficking, humanitarian border management, migrant smuggling, border management, and the Migration Information and Data Analysis Systems (MIDAS). IOM INTERNATIONAL ORGANIZATION FOR MIGRATION

35 ANNEX 3: DEFINING INTERVENTION STRATEGIES ALONG THE 3 STAGES OF AN EPIDEMIC CURVE An epidemic curve provides a graphical display of the numbers of incident cases in an outbreak or epidemic, plotted over time. The form of the resulting distribution of cases can be used to propose hypotheses on the stage of the disease and its mode of transmission. The course of a population outbreak is most evident in infectious disease, but also occurs in situations, such as a chemical spill leading to cases of respiratory disease. Disease spreads from person to person up to a peak, and then tapers off as potential hosts are exhausted from the population. Underneath the curve is a second curve, showing deaths caused by infections. There are of course major classes of epidemic curve, however the one below (see Figure 9) shows the epidemic curve for a Common Source Outbreak. Here the cases of disease arise from a single, shared or common source, such as a batch of bad food, industrial pollution or a contaminated water supply. Controlling the source stops the outbreak. Ebola is an example of a propagated epidemic. Due to person-person transmission one may see different waves of the epidemic as different groups of people are exposed. A curve like the one below might be seen as an infection moves from village to village. The time interval between the peaks corresponds to the average serial interval. The serial interval is the time between the same stage of disease (e.g. fever onset or rash) in successive cases in a chain of transmission. Figure 9:: EVD Epidemic Curve, showing the number of confirmed EVD cases reported per week in Guinea and Sierra Leone from February 2014 through August 2015 (source: World Health Organization) RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

36 32 INTERNATIONAL ORGANIZATION FOR MIGRATION Figure 10:: IOM s EVD Response Interventions throughout the West Africa Region (August 2014 to August 2015)

37 COUNTRY STRATEGIES RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

38 GUINEA NEEDS ANALYSIS As of late October 2015, the Ebola virus disease (EVD) outbreak in West Africa in Guinea has led to the infection of 3,805 people, resulting in more than 2,533 deaths. Despite these losses, the Guinea Government and population, with support from its international partners, have led a significant response which has seen the reduction in average weekly cases to less than five. Despite this progress, the potential for a resurgence of EVD cases remains a threat not only to Guinea, but also to its neighbours. It is vital that surveillance at Points of Entry (PoEs) and assessments of health surveillance capacity continue, in order to reduce the risk of cross-border EVD transmission and enable governments and international organizations to quickly deploy resources to fight any future outbreaks before they spread to major population centres. The Guinean Government has identified the strengthening of community health systems, including those near borders and other areas of high human mobility as a priority for the last phase of the response and the recovery. This includes reform of the epidemiological surveillance system in border areas, stricter application of the International Health Regulations (IHR) and a variety of other activities related to public health and human mobility. Further, the social and economic consequences of the epidemic have had an enormous impact on the country as a whole. According to the Guinean Government, 6,000 children lost one or both parents to EVD, and 600 women were widowed. Now, many of Guinea s 1,270 cured EVD survivors, as well as orphans and spouses of EVD victims, are struggling to meet their basic needs while they experience discrimination in employment and education, and exclusion from community and cultural life due to the enormous stigma attached to EVD survivorship. Compounding this is the unclear long-term prognosis for survivors, especially survivors who are presently experiencing debilitating or even disabling complications, as well as depression due to the loss of loved ones during the outbreak and the weight of stigma in its aftermath. Moreover, there is emerging evidence that some survivors have reservoirs of live virus in their eyes and reproductive organs for at least several months after they are cured. The reintegration of survivors and others directly affected by EVD is one of the major challenges facing Guinea in the wake of the crisis, and the most vulnerable survivors urgently need effective advocates within civil society, livelihoods assistance, and psychosocial support services (PSS). As a result, the recovery phase presents significant challenges for the Government of Guinea and its people. These challenges include, inter alia, the reconstruction of the primary health care system, including efforts to prevent the reemergency of the virus; support to survivors, ranging from continuing medical care to psychosocial support to economic recovery; and economic recovery in general, taking into account the fragility of the economy prior the epidemic and the disastrous consequences EVD has had on it and on society, as a whole. PROPOSED STRATEGY As the Ebola response has progressed, Guinea has managed to drastically reduce the number of new weekly cases and to contain them to the area of Lower-Guinea. However, the need to evaluate surveillance capacity in border areas and points of entry remains crucial to consolidate past gains and prepare for the future. The reinforcement of epidemiological surveillance capacities around points of entry are among the priorities identified by Guinean authorities - Ministry of Health and the National Coordination for the fight against EVD (CNLEB)- and their partners to reinforce Guinean epidemiological surveillance systems. IOM has been assisting Guinean authorities in the development of post-ebola strategies and accompanying activities. As of July 2015, the Presidency of the Republic, the Ministry of Health, and the CNLEB have been working in concert to prepare the post-ebola phase, including strengthening health systems in border areas, supporting survivors, and promoting socioeconomic recovery. 1. ENABLING COMMUNITY RESILIENCE AND RESTORING ESSENTIAL SERVICES 1.A. SUPPORT TO EBOLA SURVIVORS The socioeconomic impact of Ebola was significant throughout Guinea, but it was particularly devastating to those most directly affected by the virus. It is for this reason that the government and IOM see supporting Ebola survivors, as a priority in this phase of the response and recovery. Responding to the direct request of the CNLEB, IOM is supporting Guinean health authorities in the design, development, and implementation of the national strategy to support EVD 34 INTERNATIONAL ORGANIZATION FOR MIGRATION

39 survivors. IOM s strategy is focused around the following priority areas of intervention: Delivering mental health and psychosocial support (PSS) to survivors, and fight discrimination at a community and national level: Evaluate psychosocial and mental health needs of survivors; Reinforce the capacities of survivors associations, including training members in psychosocial support (PSS), organizational management, and advocacy; Deliver mental health care for the most vulnerable survivors or victims of mental pathologies because of EVD; Implement activities intended to fight the stigmatization of survivors and promote community reconciliation (awareness-raising, dialogues, theatre, etc.); and Organize public awareness campaigns through local and national media to fight stigmatization linked to EVD (spot radio/tv). Supporting the socioeconomic recovery of the survivors of Ebola through cash transfers and in-kind support: Identify households of survivors who are the most vulnerable from a livelihoods standpoint in IOM s zones of intervention; Administer cash transfers to eligible survivors in order to allow them to meet their most urgent needs (housing, food, hygiene, education); and Administer in-kind donations for particularly vulnerable persons (children, students, handicapped people, and widow-headed households). 1.B. SOCIOECONOMIC RECOVERY The EVD epidemic and the measures used to contain it caused great damage to a Guinean economy that was already fragile before the emergence of this health crisis. Guineans employed in particularly vulnerable sectors, such as women who work in the informal economy, were significantly affected by border closings, prohibitions of public gatherings, interruptions to planting or harvests due to movement restrictions, cessation of cross-border trade, and the loss of the foreign investment. IOM s strategy is focused around the following priority areas of intervention: Protecting the most vulnerable households: Cash transfers and in-kind support: IOM will work with the Ministry of Social Affairs and the Promotion of Women and Children to support economic recovery of the most vulnerable households by administering cash transfers in priority areas. IOM will transfer funds to households that correspond to strict vulnerability standards to allow the households to cover their basic needs (housing, food, hygiene, etc.), or to launch income-generating activities. IOM will also give in-kind support to provide for the specific needs of vulnerable survivors and orphans (for example, replacing objects destroyed by disinfection teams); and Technical support for child protection: IOM will work with the Ministry of Social Affairs and the Promotion of Women and Children to create a national database of Ebola orphans to facilitate their receiving of care and support. IOM will also work with communities to reactivate community-based child protection systems through targeted trainings and in-kind support. Restoring livelihoods: Supporting the economic recovery of small-scale farmers and tradesmen in regions of high population mobility through activities the increase in the means of subsistence: beneficiaries will have the opportunity to choose from a menu of options, which includes agricultural inputs, tools and equipment, cash subsidies, and training that will enable them to better manage their own recovery process. Rehabilitating community infrastructure: To bring small in-kind subsidies to community organizations for the rehabilitation of community infrastructure in the regions of high mobility. With an aim of facilitating the economic recovery of the communities that were significantly affected by the EVD crisis, IOM will support the rehabilitation of basic community infrastructure through targeted subsidies. The majority of these subsidies will support the rehabilitation of public infrastructure RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

40 related to water and sanitation. Supporting the economic recovery of small and medium enterprises (SME): In order for small and medium enterprises (SME) to take an active part in the economic raising of the country, IOM will offer the following support to qualifying SMEs (especially those working in the WASH sector): Small cash subsidies; training in the development of the business, marketing, and behavioural change; and Microfranchises with an aim of spreading the availability and the diversity of WASH services. 2. HEALTH, BORDER AND MOBILITY MANAGEMENT 2.C. REINFORCEMENT OF BORDER HEALTH SYSTEMS In Guinea, people pass between countries very freely through informal crossing points all along the country s porous borders. This situation demands that epidemiological surveillance is integrated into all activities centred around points of entry, local health systems, and border communities to prevent the spread of epidemic diseases between countries. A shift in paradigm is now necessary: it is time to move away from the logic of isolated targeting of individual points of entry, and time to move towards an integrated intervention model. This model is described below in terms of five objectives and priority areas of intervention that target vulnerable border and migratory zones. IOM s strategy is focused around the following priority areas of intervention: Reinforcement of the capacities of the Ministry of Health and partners related to the risks of diffusion of diseases via migration in border zones: Evaluate borders health management capacity around points of entry, local health structures, and community health care systems; Produce periodic reports and maps of migratory flow monitoring; and Identify zones and sites at risk of transmission of the virus due to cross-border mobility. Reinforcement of surveillance mechanisms for EVD and other epidemic diseases at points of entry: Support the Ministry of Health in consolidating standard operating procedures for prevention, early warning, and response to public health events at points of entry; Provide necessary equipment to install health checkpoints at borders and along major roads; Reinforce the capacities of agents at health checkpoints via trainings and simulation exercises; and Reinforce infrastructure at points of entry to allow an optimal capacity for health surveillance. Building capacity for surveillance and case management in health structures in border areas: Reinforce health infrastructure to allow for better epidemiological surveillance capabilities; Reinforce competencies of health workers via trainings and stimulation exercises; and Provide basic equipment to targeted health structures and provide training on stock management. Accompanying border and maritime communities in the reconstruction of their community health care systems (both modern and traditional): Strengthen the primary health care system in areas of high human mobility through rehabilitation, reconstruction, provision of key equipment, training and related activities; Engage communities in taking responsibility to protect themselves and their country from future epidemics; Support communities in the implementation of their own community action plans for health surveillance; Reinforce the confidence of the communities in the Guinea health system; and Improve information exchange between cross-border communities to reinforce their knowledge and increase health promotion. Strengthen multi-sector and cross-border collaboration: Support the Ministry of Health in the implementation of emergency public health plans and standard operating procedures at points of entry; Provide technical support to the National Committee of Health Crises (CNCS) and to the National Centre for the 36 INTERNATIONAL ORGANIZATION FOR MIGRATION

41 Prevention and Control of Epidemic Diseases (CNPCM), taking into account of cross-border cooperation and understanding of human mobility; and Support the Ministry of Health in establishing multi-sectoral partnerships (intergovernmental and public-private) and inter-country cooperation frameworks. EXPECTED IMPACT The expected impacts of IOM Guinea s Ebola recovery strategy are as follow: Support to survivors: EVD survivors associations become effective advocates for the rights of EVD survivors; EVD survivors have their immediate needs met and can recover from the socioeconomic effects of the crisis; and EVD survivors are emotionally well and accepted in their communities. Socioeconomic recovery: Basic needs of vulnerable households are met and the households overcome the economic impacts of the EVD epidemic; Community infrastructure is rehabilitated in areas of high human mobility and which have been badly affected by the epidemic; Means of subsistence in badly-affected border areas are re-established for small farmers and small businesses; and The availability of minimum WASH services in areas of high human mobility is improved. Reinforcement of border health systems: All official and unofficial PoEs are mapped and categorized, health facilities in border and coastal sub-prefectures are inventoried and mapped, and this data is made available in user-friendly forms to other key health actors; Health control agents at PoEs have the equipment and materials they need to safely and effectively carrying out their surveillance tasks; Health control agents at PoEs have the training they need in order to effectively carry out surveillance for EPDs; Health workers and community members in vulnerable border and coastal sub-prefectures can identify potential EPD cases and appropriately refer them to the nearest functional health facility; Health facilities in vulnerable border and coastal sub-prefectures are equipped with the structures and trained staff necessary to serve as referral facilities for potential EPD cases identified at PoEs or in communities; and Surveillance actors at PoEs are fully integrated into the national EPD surveillance system and are regularly sharing data with each other and with their counterparts at other levels and in neighbouring countries. COORDINATION AND PARTNERSHIP National authorities: IOM works primarily with the Ministry of Planning, the Ministry of Security, Ministry of Information, the Ministry of Youth and Youth Employment, the Ministry of Social Affairs and Promotion of Women and Children, the Ministry of Agriculture, the Ministry of Guineans Living Abroad, the CNLEP, the Ministry of Health, the Maritime Prefecture, the National Statistics Institute, and the Ministry of Transport. International community: IOM, as an intergovernmental organization, is part of the United Nations system in Guinea and is an active member of the United Nations Country Team. In an emergency, IOM is actively involved in the cluster coordination system and is designated lead agency for the CCCM cluster in the case of a natural disaster. IOM also works with non-governmental organizations and embassies present in Guinea. Particularly with regards to health programming IOM works in close collaboration with the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). Private sector: The private sector can play a crucial role in the development of a country through creating income generating opportunities, improving the living conditions of its employees, and implementing social projects (also known as Corporate Social Responsibility - CSR). The Guinean private sector, which was active in CSR projects before RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

42 Ebola, has actually invested little in the fight against EVD. The outbreak of the epidemic actually led to the suspension of activities of many multinationals and foreign investors. As the end of the epidemic approaches, there is a gradual return of the international private sector (particularly mining) to Guinea, which presents an opportunity for companies participate in the economic revival of Guinea and certain CSR projects. IOM will continue to work in the country to find synergies with the private sector to increase the revenue of Guinea, while improving the conditions of communities and people living near large industrial projects (such as mines). STRATEGY OPERATIONALIZATION: PROPOSED PROJECTS Projects Provisional Budget Reinforcement of border health systems USD 15,276,825 Support to Ebola survivors USD 2,017,057 Socioeconomic recovery USD 12,132,608 Total USD 29,426, INTERNATIONAL ORGANIZATION FOR MIGRATION

43 LIBERIA NEEDS ANALYSIS The recent Ebola Virus Disease (EVD) crisis affecting Liberia since March 2014 was unprecedented in scale, with World Health Organization (WHO) reports indicating over 10,500 people infected resulting in over 4,800 deaths, including 192 health care workers (WHO report October 2015). The outbreak has affected Liberia at a time when the country was recovering from more than a decade of devastating civil war, critically impacting recent socioeconomic development across the country. EVD exposed and exacerbated chronic vulnerabilities in Liberia s public health infrastructure and institutions. EVD forced the closure or decreased service provision in many health facilities in the country, caused the suspension of routine essential health services and significantly reduced utilization of health services as outpatient visits fell by 61%. As the focus necessarily shifted towards EVD, attention to other priority diseases declined; for example during the crisis 60% of the 144 HIV/AIDS centres in the country closed (The Lancet, February 2015). Hence, EVD increased the potential for a surge of other non-evd-related health concerns. Further, at the local primary health facility level, operational and management challenges continue to limit health system effectiveness. The Ministry of Health has identified urgent health system restoration priorities, which aim to reduce the threat from all health concerns. Further, the devastating socioeconomic effects caused by the outbreak in Liberia demonstrated the wider impact of large-scale health emergencies and highlighted the complex relationship between health system resilience, human mobility and economic development. Widely enforced quarantine, isolation and movement control measures (notably border closures which restricted the movement of people, goods and services) intended to limit EVD transmission, contributed to a significant decline in economic activity in Liberia. GDP growth fell from 5.9% in December 2013 to 0.3% in December 2014 and contributed to acute food shortages in the country. The World Food Program (WFP) estimates that the number of food-insecure people in rural areas in 2015 will increase to 2.7 million (60% of the population); an increase of 1.5 million people from EVD worsened entrenched disadvantages among key populations, including youth and cross-border traders, due to the instability of economic opportunities, the indirect impact of the disease on livelihoods, household market dependency, and EVD infection rates. 1 Greater still has been the impact on rural communities, particularly remote border communities, which are more isolated and impoverished than other areas, facing political, social and economic marginalization. Seasonal economic opportunities in cross-border areas, including work in plantations and mining, encourages irregular migration and as a result, border villages, key migration routes and places of public gathering were vulnerable hotspots for EVD transmission and importation. The outbreak highlighted gaps in national and local capacity to prevent, detect and respond in the event of communicable disease outbreaks (including EVD), particularly at points of entry and in border communities, and remain a burden on recovery. PROPOSED STRATEGY 1. ENABLING COMMUNITY RESILIENCE AND RESTORING ESSENTIAL SERVICES 1.A. RESTORING ESSENTIAL HEALTH SERVICES IOM intends to support the Ministry of Health (MoH) to restore and expand provision of essential health services in areas of high human mobility, particularly in border communities and remote areas. IOM will work at the central (Monrovia) and local (County and District) levels to increase access and quality health service delivery through technical assistance and capacity building and by addressing key requirements to ensure adequate infrastructure. To achieve this, IOM Liberia will align its strategic areas of intervention to five key pillars of the MoH Investment Plan: Fit for purpose productive & motivated health workforce Re-engineered health infrastructure Epidemic preparedness and response system Enhancement of quality service delivery systems Sustainable community engagement 1 Over 95% of women in Liberia are engaged in small businesses which were disproportionately impacted during EVD - 60% of women versus 40% of men had to cease work by December RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

44 IOM Liberia strategic areas of interventions are: Supporting capacity building of health workforce through diaspora engagement: IOM facilitates the transfer of knowledge, skills and experience from the diaspora, through long-term and shortterm return or online capacity building. To contribute to the health sector development in Liberia, IOM intends to map and support engagement of skilled diaspora for capacity building of health care workers, the Ministry of Health (MoH) and academic institutions. Upgrading health facility infrastructures to ensure essential Infection Prevention and Control (IPC) standards: During 2015, IOM upgraded 27 health facilities (HF) establishing triage and isolation units as well as required WASH infrastructure. IOM intends to continue targeting HFs, particularly in proximity to border areas, and along target routes and hotspots. Building capacity for surveillance and response at national, county and community levels: IOM will support community-events based surveillance (CEBS) through training, mentorship and support to health actors and general community health volunteers (gchvs) in border communities in Grand Cape Mount, Gbarpolu, Lofa, Bong, Nimba, Grand Gedeh, River Gee and Maryland. In addition, IOM will provide direct support to MoH and CHTs to ensure relevant screening, infection prevention and control, isolation and referral capacity, and effective data collection at ports of entries. Moreover, it will build the capacity of MoH and County Health Teams (CHTs) to independently lead Emergency Preparedness and Response activities in Bomi, Gbarpolu, Grand Cape Mount, Grand Gedeh, River Gee and Maryland, as per the IDSR National Policy. IOM will ensure that CHTs have the knowledge, skills and resources to provide all aspects of case management in the event of an outbreak. It will expand on-going activities to strengthen community resilience by engaging communities in county EPR plans. Improving access to Quality Basic Health Services in remote and border areas through mobile clinics: IOM has been supporting CHTs to conduct regular mobile clinics in Bomi, Grand Bassa and Grand Cape Mount counties, to provide primary health care, vaccination and maternal and child health services to communities who lack access to essential health services. IOM intends to continue to provide mobile clinics in under-served areas, while ensuring CHTs have the technical capacity to eventually provide these services. Mentorship for Quality Health Service Provision: IOM has been supporting delivery of MoH Safe and Quality Service (SQS) Provision training. To support sustainability of SQS in Liberia, IOM intends to implement a health facility mentorship programme - with clinical and non-clinical components - at health facilities in GCM, Bomi, Grand Bassa and Maryland. This will ensure that health facilities function and health care workers meet acceptable clinical and operational standards while restoring confidence in county health facilities lost through the EVD crisis. Supporting community engagement for health promotion: IOM will build on its engagement with over 2,500 general Community Health Volunteers (gchvs), by complementing CEBS activities with health promotion in communities, primarily in border areas. This will focus on raising awareness of key public health messages to prevent or contain the possible spread of priority communicable diseases within communities, under the framework of the national IDSR strategy. 1.B. ENABLING COMMUNITY RESILIENCE IOM community resilience strategies are aligned with the Government of Liberia s 2015 Economic Stabilization and Recovery Plan (ESRP). Specifically, IOM intends to support Strategy 2 aimed at strengthening resilience and reducing vulnerability. The IOM community resilience approach focuses on economic revitalization of the most marginalized and at-risk groups in areas affected by high mobility, particularly youth and women, as well as supporting the Government of Liberia in ensuring delivery of key basic services for vulnerable communities. IOM will address the immediate needs of the most vulnerable groups through trainings, livelihood support and protection assistance. IOM will support authorities to increase access to key services, including water and sanitation, and build capacity to cope with future disasters, and to improve migration management. IOM Liberia strategic areas of interventions: Livelihoods Support for Mobile Populations: 40 INTERNATIONAL ORGANIZATION FOR MIGRATION

45 IOM intends to provide financial and technical support to restore livelihoods and re-establish local market systems for mobile populations, including fisherman and cross-border traders, including in Grand Bassa, Grand Cape Mount and Maryland. Training and Capacity Building for Youth and Vulnerable Groups: IOM aims to enhance employment opportunities for youth and other vulnerable groups, through access to skills development and tertiary and vocational education (TVET) in border counties. Slum Upgrading and Increased Youth Employment in Urban Areas: IOM will support urban recovery and disaster risk reduction through participatory slum upgrading and WASH interventions in Montserrado County. Access to Water, Sanitation and Hygiene Services in Communities: Through the EVD response, IOM has been supporting the improvement of WASH in health facilities and schools in Bomi, Grand Bassa and Grand Cape Mount. IOM intends to continue to improve water and sanitation conditions for vulnerable rural communities, including enhanced access to WASH infrastructure (particularly in health facilities and schools) and hygiene promotion. Decentralized Emergency Response Capacity and Disaster Risk Management: IOM intends to support the Ministry of Internal Affairs to build the capacity of County Disaster Management Committees in border counties and support operationalizing Disaster Risk Management systems at County and District levels. Building Government Capacity against Human Trafficking: The economic and social crisis caused by the EVD outbreak has increased vulnerability of communities and specific groups to human trafficking. IOM intends to continue supporting the efforts of the Government of Liberia to scale up the fight against human trafficking by building capacity of law enforcement officials in all counties, raising awareness nationally and specifically among vulnerable communities, and improving protection systems. IOM will continue to provide direct assistance to victims of trafficking and technical assistance to the Ministry of Justice, Ministry of Labour and Anti-Human Trafficking Taskforce to finalize and apply the National Referral Pathway/Mechanism for victims of trafficking. Integrated and Humanitarian Border Management: The Security and Justice Transition strategy is a key element of the National Recovery Plan. IOM intends to support the Security and Justice Transition Plan and ensure protection of vulnerable migrants, by strengthening the operational, human resources and information management capacities of border actors, particularly the Bureau of Immigration and Naturalization. Further, IOM will support integrated border management as well as humanitarian border management during complex migration crisis. 2. HEALTH, BORDER AND MOBILITY MANAGEMENT (HBMM) Mapping and analysing human mobility patterns: IOM is committed to improve knowledge of mobility patterns in Liberia for public health intervention. Working with partners and communities, IOM will collect and analyse data on human mobility through participatory mapping for identification of hotspots and monitoring of flows. Compliance to International Health Regulations (IHR): IOM intends to provide technical support to the Government of Liberia to ensure International Health Regulations (IHR) compliance at all land, sea and air ports of entry by increasing the capacity of Port Health to detect and respond in the event of communicable diseases. IOM intends to strengthen technical and operational capacity of Port Health, as well as its ability to work in an integrated manner with other border agencies, and to contribute to the implementation of the National IDSR strategy. EXPECTED IMPACT 1. RESTORING ESSENTIAL HEALTH SERVICES In the short term, health system support will contribute to maintaining zero cases and preventing the resurgence of communicable diseases by ensuring essential IPC standards in health facilities, sufficient response capacity of health RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

46 workers mentored to provide safe and quality services as well as an essential level of surveillance in remote areas through mobile clinic services. In the mid and long term, this would increase public trust in the health system, improve access to essential primary health services, re-establish routine health service delivery and build the necessary capacity for sustainability. 2. ENABLING COMMUNITY RESILIENCE Quick impact interventions targeting youth and small-scale women traders will, in the short term, restart cross-border trade, food production and local market systems by providing the most vulnerable with financial support through cash transfers and cash-for-work. In the medium and long term, training and technical support would enable sustainable livelihoods for youth, support their economic recovery, and reduce security risks in the targeted border communities. Access to water, sanitation and hygiene services will lower the risk of water borne and other communicable diseases and high child mortality. 3. HEALTH BORDER AND MOBILITY MANAGEMENT (HBMM) The expected impact of HBMM interventions is to provide evidence on human mobility for informing future public health intervention and support evidence-based policy development, while building the capacity of MoH and communities to implement IDSR strategy at ports of entries and in border communities. COORDINATION AND PARTNERSHIP Since 2014, IOM Liberia has been enhancing the technical and operational capacity of the Ministry of Health (MoH) and local providers of health services. IOM has worked closely with the MoH, providing technical analysis and assessments that led to the definition of the MoH Investment Plan, as well as contributed to the finalization of the IDSR Strategy (including technical manual and data collection tools), through active participation in several MoH-led technical groups on surveillance. IOM is Secretariat of the Border Coordination Group, chaired by the MoH, for the coordination of border surveillance. IOM is also a member of a Consortium of 8 partners formed to build the capacity of the MoH at central and county level for Emergency Preparedness and Response. IOM has been operating in Liberia since Initially, the mission s focus was supporting post-conflict recovery through: family reunification and assisted voluntary return assistance to Liberians; disarmament, demobilization, reintegration and resettlement programmes with ex-combatants; and relocation of internally displaced persons (IDPs). Subsequently, the mission expanded operations to include providing capacity building, technical assistance and operational support to GoL in the areas of migration management, including support to develop a National Migration Policy and counter trafficking, including enhancing the capacity of the Anti-Human Trafficking Taskforce to implement the 2005 Act to Ban Human Trafficking. 42 INTERNATIONAL ORGANIZATION FOR MIGRATION

47 SIERRA LEONE Sierra Leone is in the midst of emerging from an unprecedented Ebola Virus Disease (EVD) outbreak that devastated the population, severely affected Sierra Leoneans through the loss of family and community members, disrupted economic growth and further weakened a fragile health services system through the unfortunate deaths of several prominent medical practitioners. On 23 May 2014, Sierra Leone recorded the first case of Ebola Virus Disease (EVD) in Kailahun district in the remote eastern part of the country bordering Guinea and Liberia. The outbreak rapidly spread from a localized to general epidemic, shifting from the sparsely populated east to more densely-settled urban and peri-urban areas in the west. Sierra Leone recorded the highest rate of EVD transmission worldwide with over 14,122 confirmed, probable and suspected EVD cases and 3,955 deaths as of 01 December 2015, according to the World Health Organization (WHO) 1. International health experts and governments of affected countries recognized that factors contributing to the spread of the EVD outbreak include a new disease in a new context; health systems weakened by conflict and instability; high population mobility across porous borders; cultural and behavioural practices; reliance on traditional healers; and suspicion and growing resistance towards health authorities and humanitarian actors 2. The dire impact of EVD on a cross-sector scale has led to critical needs in 3 major sectors of IOM Sierra Leone Strategy focus: 1) Health Systems Sector The Ebola outbreak in Sierra Leone has had direct and indirect impacts on the capacity of the health care system in all three most affected countries, but significantly in Sierra Leone where health care workers infected with Ebola (307) and deaths (221), including 11 prominent physicians, out of a total health care worker population of roughly 2,400 (estimated by US CDC) reflects a significant loss of valued human resources in the health sector and consequently an inability to provide broad access to basic and primary health care. The deaths of experienced health workers and those who supported the health system administration, is a compounding deficit that will take a generation of education, training, and experience to replace. While the international community has responded to EVD for containment and control, and in doing so has supported the provision of EVD specialty care, primary care services, and public health expertise, the health system remains fragile. The ratio of health workers per population size has declined from an already low level of 17.2 per 10,000 population before the outbreak to 3.4 per 10,000 population currently. 3 Evidence shows that lack of Infection Prevention and Control (IPC) measures contributed to the rapid spread of Ebola. The health sector experienced a range of direct and indirect effects as a result of the epidemic: closure of health facilities, the deaths of health care personnel, disruption of the medical supply chain, and mistrust by local communities toward the health care system. As a result Sierra Leone s health sector priorities shifted to EVD outbreak management. The epidemic also reduced the effective response to other diseases by the national health care system. The number of reported cases of malaria, measles and non-ebola illnesses increased dramatically during the Ebola outbreak. Reporting of malaria cases to facilities dropped by an estimated 42% as a result of growing mistrust of the health care system. 4 Therefore the need to strengthen the overall health system, particularly in terms of patient and health worker safety, health workforce and essential health services, is imperative. 2) Human Mobility and Health The rapid transmission of the disease from neighbouring countries has demonstrated the weakness of the health systems at the border. Therefore, reinforcing health capacity at the border is required to address the public health imperatives of preventing, detecting and responding to EVD and other infectious diseases along the mobility continuum at origin, transit, destination and return points. In order to mitigate the risk of future epidemics, it is vital that a robust, integrated border health system network, consisting of border health posts linked to Peripheral Health Units (PHUs) as well as referral health facilities, is established. The four components of capturing human mobility, IPC training / mentorship, community social mobilization and health infrastructure upgrade are integral to the overall strengthening of border health systems. 3) Economic and Social Sector The economic and social impacts of EVD are massive and yet to be completely understood. The World Bank has estimated the virus has cost the affected nations more than US$2 billion over Over 180,000 jobs were 1 World Health Organization Ebola Situation Report National Ebola Recovery strategy for Sierra Leone Ebola to Blame for More Malaria Deaths in West Africa. RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

48 lost in Sierra Leone and WFP suggests that over 3 million people are food insecure in a country of about 6 million persons 5. In the wake of the crisis, many of the land borders across West Africa were closed, cutting off trade and the movement of people, including women that depend on informal cross-border trading to sustain household incomes and livelihoods. The majority of multinational companies operating in Sierra Leone have pulled back new investment, repatriated many foreign workers and cut production of critical revenue generating exports. Their economic plight has been exacerbated by the simultaneous drop in iron ore prices on international markets, adding to the revenue woes of the mining economy. To contain the epidemic, the affected countries closed their borders with each other and most of their neighbours. Many countries within Africa banned citizens from the three countries from entering their borders as well as travellers who had been to the affected areas. The majority of airlines stopped flights into Sierra Leone with only two airlines continuing flights, SN Brussels and Royal Air Maroc, through the height of the crisis although many airlines have since resumed operations. Visitors, both from Africa and outside of the region, have avoided West Africa for fear of illness, resulting in drastically reduced tourists demand for hotels, airlines and service providers. Therefore, the need to ensure the resumption of full air, sea and land transportation is crucial for the return of the investment to the country. PROPOSED STRATEGY The IOM Sierra Leone EVD Recovery Strategy consists of three pillars, including Enabling Community Resilience and Restoring Essential Services, Border Management and Training & Capacity-Building. 1. ENABLING COMMUNITY RESILIENCE AND RESTORING ESSENTIAL SERVICES IOM will focus on the following interventions within the pillar of Enabling Community Resilience and Restoring Essential Services: Stabilization of EVD-affected communities through livelihoods, small grants and psychosocial support Strengthening IPC and WASH in health facilities and educational institutions Restoring essential health services through diaspora engagement 1.A. STABILIZATION OF EVD-AFFECTED COMMUNITIES: Sierra Leone has 10,046 survivors accounting for around 58% of all survivors in the three most affected countries. These survivors, their families and their communities have faced a devastating economic, social and psychological toll as a result of EVD. Through extensive programming in social mobilization, including the innovation of cultural burial liaisons, and in-house expertise on mental health and psychosocial support, IOM will concentrate on stabilization of EVD-affected communities to ensure these communities have the economic and social means required to recover. 1.B. STRENGTHENING IPC AND WASH IN HEALTH FACILITIES AND EDUCATIONAL INSTITUTIONS: IOM has supported the Ministry of Health and Sanitation (MOHS) and partners to develop a health sector recovery framework that forms the basis of the recovery strategy for Sierra Leone. The key principles of the Health Sector Recovery Framework include International Health Regulation (IHR) Compliance, Patient and Health Worker Safety and Disease Surveillance. In support of MOHS and GoSL, IOM has developed and aligned a comprehensive strategy with this recovery framework. The EVD outbreak revealed astounding gaps in the water, sanitation and hygiene (WASH) and IPC of health facilities on a nationwide scale, including in private health facilities which receive around 25% of total patient flow. In collaboration with MOHS and partners, IOM has undertaken a comprehensive needs assessment of WASH, IPC, supply chain, training and waste management across 30 private health facilities and is currently strengthening WASH and IPC in 21 of these facilities assessed as the most critical in need. In light of a formal MOHS request to support WASH and IPC in an additional 75 private health facilities, IOM plans to activate a project Phase II for these additional facilities from January C. DIASPORA ENGAGEMENT: As previously elaborated, health care system human resources, including doctors, nurses and administrators, have been depleted as a result of the outbreak. Prior to the EVD outbreak, IOM completed an extensive survey of Sierra Leone diaspora health workers in the UK, Germany, USA and Canada revealing a high number of diaspora health workers willing to return to Sierra Leone to mentor and build the capacity of SL health care workers. IOM intends to facilitate the return of diaspora health workers to Sierra Leone in order to urgently fill the staggering deficiency of doctors, nurses and administrators while building capacity in local human resources for future generations. 5 Food Insecurity on the Rise as Ebola Abates. wfp.org/stellent/groups/public/ documents /ena/wfp pdf 44 INTERNATIONAL ORGANIZATION FOR MIGRATION

49 2. BORDER MANAGEMENT IOM will focus on the following interventions within the pillar of Border Management: Health, Border and Mobility Management (HBMM) Immigration and Border Management (IBM) 2.A. HEALTH, BORDER AND MOBILITY MANAGEMENT (HBMM) HBMM aims at tackling the spread of communicable disease through prevention, detection and response activities along mobility corridors and in cross-border areas, while enhancing health systems, inter-sector communication and partnerships and international cooperation. IOM is recognized as the United Nations Country Team (UNCT) lead agency on border management and is currently implementing a health border management project focusing on comprehensive monitoring of health screening at vital land, sea and air international and internal border crossing points in order to mitigate the risk of EVD cross-border contamination. The project includes capacity building of Port Health authorities, provision of IPC materials, IPC training of health screeners and monitoring, evaluation and reinforcement of the health screening system nationwide. In order to prevent and/or contain disease outbreak in the future, supporting and strengthening surveillance systems in border regions and along migration pathways is of utmost priority. This will be achieved in line with national surveillance strategies and Integrated Disease Surveillance and Response (IDSR) plans. Additionally, collaboration and capacity building will be promoted with local authorities and government agencies, such as the Ministry of Health and Sanitation, the Office of National Security and Statistics Sierra Leone. Activities will include the mapping of mobility patterns and congregation hubs, cross-analysis with health risks and capacities, and its integration into decision-making and surveillance strategies at local and national levels. Furthermore, a second priority area is continually building capacity at major air, sea and land Ports of Entry (PoEs) to prevent, detect and respond to communicable disease threats and their integration into the national and regional reporting structures. All major PoEs will be assisted in reaching the core capacities required in the International Health Regulations (IHR) (2005) and the requirements defined by the International Civil Aviation Organization for Freetown International Airport. Activities will include the development of plans and SOPs, material and infrastructure support to meet IHR compliance, and the implementation and institutionalization of a comprehensive training and exercise program that can be passed on to local and national authorities. Finally, the third priority area is to support the bi-national and regional communication and coordination systems to prevent, detect and respond to communicable disease threats. Activities will include the support and strengthening of cross-border coordination groups, the development of MoUs and SOPs for sharing of surveillance and communicable disease response information, bi-national workshops to facilitate better communication and coordination, and the training and testing of these cross-border systems. 2.B. IMMIGRATION AND BORDER MANAGEMENT (IBM) IBM objectives are focused on assisting the Government of Sierra Leone improve policy, legislation, administrative structures, operational systems and the human resource base necessary to respond effectively to migration and border challenges in line with institutionalization of good migration governance. IOM will support the government to review the existing migration regulatory framework in order to effectively manage migration and protect the rights of migrants, whilst ensuring border security. Free movement and trade facilitation will constitute a central component to the Sierra Leone migration management tool, which must conform to international standards. IOM works regionally with ECOWAS to support the development and operationalization of a new regional migration policy framework. Consequently, IOM will provide technical assistance to Sierra Leone for implementing the ECOWAS Common Approach to Migration, and ECOWAS Protocol on Free Movement. An initial IOM-led border assessment exposed significant deficiencies in infrastructure, communications and IT equipment that seriously restrict the government s ability to manage its borders. Additionally, the majority of PoE feature non-existent or inadequate Global System for Mobile Communication networks which impede the efficient and accurate transfer of information. IOM aims to promote the implementation of the Migration Information and Data Analysis System (MIDAS) and its connection to Interpol I24/7, and will facilitate the related capacity building, training of immigration officers, and infrastructure development needs. 3. TRAINING AND CAPACITY BUILDING IOM will focus on the following interventions within the pillar of Training & Capacity-Building: IPC training and capacity building in health care facilities RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION

50 IPC short-course departments in Colleges of Medicine Flood Disaster Risk Reduction Low income community-based waste management and upgrading 3.A. IPC TRAINING AND CAPACITY BUILDING IN HEALTH CARE FACILITIES: IOM is recognized as the most operational IPC training agency within the UNCT and managed the largest IPC Training Academy in the region, having trained over 10,000 front-line Ebola responders and health care workers on MOHS/ WHO/US CDC certifiable IPC training in the span of 10 months. In addition to static IPC training and health screening mentorship activities in Freetown at public and private hospitals, IOM has conducted weekly mobile training sessions to 12 of 14 districts thus far to deliver tailor made IPC training for an array of functions, such as swab takers, ambulance drivers, airport workers and hygienists. Drawing from this extensive expertise, IOM will continue to collaborate with MOHS and partners on sustainable IPC training and capacity building in health care facilities which urgently require dedicated, specialized and contextually-based IPC training programs. MOHS has officially requested IOM to provide comprehensive IPC training to 75 private health facilities. In addition, IOM has been requested by the UNCT and frontline responder agencies to maintain a mobile training surge capacity throughout 2016 in the event of another EVD outbreak and the requirement for health care workers to urgently be provided refresher training. 3.B. IPC SHORT-COURSE DEPARTMENTS IN COLLEGES OF MEDICINE: To ensure sustainability of academic IPC in colleges of medicine and upon official request of the College of Medicine and Allied Health Sciences (COMAHS) and Tonkolili Allied Health Sciences, IOM will look to activate Phase II Training Academy to institutionalize IPC short-course departments in Freetown and Tonkolili Schools of Medicine in which IPC curriculum and practical training was virtually non-existent prior to the EVD outbreak. 3.C. FLOOD DISASTER RISK REDUCTION: The most intense flooding in decades devastated some of the most poverty-stricken, densely populated, low-lying coastal communities in Freetown, Sierra Leone on 16 September 2015 resulting in an estimated 24,000 internally displaced persons (IDPs) and affected local community members across 4 districts, thousands of damaged households, significant loss of household assets and a reported 20 deaths. As Camp Coordination and Camp Management (CCCM) Global Cluster Lead for natural disasters, with CCCM activities currently in over 25 countries, including Nepal, Haiti and the Central African Republic, IOM has received an official request by the Government of Sierra Leone to support the Office of National Security, the lead disaster preparedness and response agency, with disaster risk reduction capacity building in the event of future flooding. IOM will support ONS with comprehensive CCCM Training, installation of flood mitigation measures (physical and organic barriers), national flood mapping and identification of potential open space IDP sites, drainage expansion and natural disaster response Standard Operating Procedures (SOPs). IOM will also support ONS to develop preparedness action plans for other types of hazards, including cholera and landslides. 3.D. LOW INCOME COMMUNITY-BASED WASTE MANAGEMENT AND UPGRADING: With several hundred thousand people densely packed into slum areas lacking clean water, sanitation and hygiene, waste management in Freetown remains a significant concern for future infectious disease outbreaks. Slum sewage systems are presently non-existent and laneway gutter systems are already overflowing. Moderate rainfall rapidly triggers flooding creating a scenario rife for cholera and other oral-fecal transmitted diseases considering the complete lack of waste management. In order to alleviate potential disease outbreaks in Freetown, a sustainable waste management intervention in low income coastal slums is required to create more resistant and resilient communities. IOM will partner with a technically proficient INGOs and local partner NGOs to clear waste from coastal slums ahead of the rainy season, install sustainable waste management systems and build the capacity of local leaders to maintain this system. 46 INTERNATIONAL ORGANIZATION FOR MIGRATION

51 IOM's Mobile Training team rapidly deployed and delivered EVD clinical training to front-line emergency responders, combating an EVD outbreak in Bombali district, Sierra Leone IOM 2015 RECOVERING FROM THE EBOLA CRISIS IOM'S STRATEGIC FRAMEWORK FOR ACTION