Health in humanitarian crises  »  Health systems  »

Health service delivery: characteristics, adaptation to humanitarian crises and evaluation tools

  • Page updated onMarch 30, 2026
Health service delivery
Text and photo: Bruno Abarca

A good health system must be able to offer the population the services it needs, in the way and in the place that is most effective. To do so, it must employ all its resources, from its health financing to the workforce and the medicines and health supplies. All these inputs are necessary for the first output produced by the system: quality health service delivery.

In addition, in humanitarian emergencies it is necessary to understand how the crisis affects the health system. Well-analyzed information will help identifying areas where existing facilities require support and adapting health service provision to the new situation. This adaptation sometimes goes hand in hand with a prioritization of essential services, and even the identification of new health service delivery modalities.

What are the characteristics of good health service delivery?

Health service delivery refers to the package of services that the health system offers, its modalities, and the infrastructure needed to do so. It is the immediate result of introducing resources into a functional health system.

Good health service delivery is determined by a number of key characteristics: 

Comprehensiveness

Under normal conditions, and despite the variations that exist between health systems, it is usual for a health system to offer services of all types. This includes diagnosis and treatment of health problems, preventive services such as routine childhood immunization or prenatal follow-up, palliative and rehabilitation services, and health promotion.

Accessibility

Services must also be accessible, without geographical, economic, cultural or language-related barriers. In this sense, primary health care is of great importance. This strategy prioritizes the provision of health services in the community, in centers close to families and hand in hand with community participation and the mobilization of community health workers with a fundamental role. In this way, equitable access to primary healthcare centers can form the heart of the system, along with second-level and third-level hospitals. This network of well-distributed facilities should be articulated with a good referral and counter-referral system.

Coverage

For people to actually use health services, it is not enough for them to be available and accessible. They must also be designed to meet the needs of the entire target population, without leaving anyone behind. On many occasions, however, there is a lack of investment in services aimed at people with fewer resources, or the foreign, immigrant or refugee population, for example, is left out of social protection schemes.

Continuity

Continuity of care is also an important characteristic, with multiple dimensions. On the one hand, there is continuity throughout the life cycle, avoiding, as far as possible, fragmentation and disconnection between the services offered according to age groups or health conditions. On the other hand, there is continuity between levels of care, so that all are articulated in an integrated and interconnected network.

Quality

The quality of services depends on many factors. These include the extent to which they are effective in alleviating a health problem, safe for patients, or offered in a timely manner without long waits. Ultimately, quality must be understood from the perspective of the people who use (or choose not to use) these services.

Person-centredness

Often, fragmentation in the organization of services or the specialization of their staff leads to a focus of services on diseases or on the best-funded priorities. The consequences of this can be dire for clients, who may not only have multiple health conditions and problems, but may also have to deal with services and professionals who only address specific issues, regardless of how these interrelate with each other or their psychosocial impact on overall quality of life.

Furthermore, health care users have the right to participate in the design of health care services, in their evaluation and in making decisions that affect them. Only in this way can the priorities of individuals and the social determinants of their health and disease be truly integrated into the biomedical.

Coordination

Good health service provision requires adequate coordination among all its facilities, departments, services, authorities and organizations. Coordination allows the same person to access emergency, preventive or specialized services offered in different centers. All of these, moreover, must be well connected with social and other services, external but complementary to health care.

Accountability and efficiency

The health authorities and the people who manage the health services are responsible for ensuring that all these characteristics are met, and that this is achieved with efficient use of available resources. For this reason, they must be accountable to the public for the fulfillment of objectives, the performance of services and the results achieved.

Health service provision in humanitarian crises

Humanitarian emergencies can disrupt or impair the provision of health services

In complex emergencies and humanitarian crises, the health system and service delivery can collapse. When this happens, the health system loses the ability to secure the resources needed to deliver the usual package of services. Health personnel are forced to abandon their posts, infrastructure is damaged and equipment maintenance is reduced, drug supply is hampered, referral and counter-referral systems are weakened, and access to services for the population (sometimes displaced or trapped in areas of high insecurity) is hampered.

In addition, new risks and disease patterns may appear as a result of the impact of the crisis on living conditions or access to water and sanitation, among other factors. At times, this ends up causing an overload of health services that do not have the capacity to cope with it.

Health service delivery, to the extent of system resilience, and sometimes with external support, must adapt to the new humanitarian context. How well it manages to absorb the shock and adapt to the crisis will determine the crisis-affected population's access to quality health services.

The health care package should be tailored to cover the essentials and priorities

In many humanitarian contexts it may be necessary for different actors to coordinate to adapt and define a new package of essential health services. In this way, the most important health problems can be addressed. This package of interventions should cover preventive services as well as curative, rehabilitative and palliative services, at different levels of care. Services must be available to all people, with good quality. Therefore, they should be provided at no direct cost to the users, as far as possible.

Having a package of services adapted to the crisis allows the development of a strategy around it, supported by political commitments, which facilitates the work of planning, resource mobilization and management of these services. At the same time, it can serve as a basis for the provision of services by all actors involved in the crisis, reducing fragmentation, increasing equity and even facilitating the implementation of common health information system tools and common reporting mechanisms.

Developing a package of essential health services, however, is no easy task. To begin with, its selection must be based on international recommendations adapted to the local burden of disease and the specific priorities of the intervention context. Moreover, in order not to remain a mere utopian aspiration, their feasibility and potential costs must be analyzed, in scenarios where resources are scarce and often not guaranteed. Some may require medications not found in the usual inter-agency kits or specialized training of healthcare personnel.

New actors and health service delivery modalities become necessary

The humanitarian actors should help ensure that the affected population has access to the health services they need. It is recommended to set a target of 80% of the population with access to primary health care services on foot (no more than one hour walking) and 80% of facilities offering the priority services. To achieve this, a sufficient network of health centers at different levels must be ensured and maintained, and external support needs for these services must be identified.

When this is unfeasible or insufficient, temporary alternative service delivery modalities arise. The most common is to deploy emergency medical teams or mobile clinics. These teams may depend on existing public centers, which deploy them to reach the population that cannot access static health services. In other cases they are operated by humanitarian organizations, which come in to temporarily cover a fundamental need, but with a risk of fragmentation. They may have different service packages to the pre-existing one, different payment regimes (generally at no direct cost to the users), independent information systems (which can hinder continuity of care in populations on the move) and sometimes wide differences in quality with respect to what was previously available.

Since 2010, efforts have been made to systematize and establish minimum standards for Emergency Medical Teams, both national and international. This has to some extent facilitated their deployment and coordination and thus health system governance during the crisis, despite the multiplicity of actors. Depending on how they are carried out, these humanitarian interventions can minimize their potential negative impact on the already damaged health system and even contribute to the first steps of its future early recovery.

How can we evaluate existing health services?

Assessing health services makes it possible to identify priorities for intervention to support them or fill their gaps

In the same way that humanitarian action always starts with an analysis of the context and needs, practically all health cooperation interventions, especially those focused on support to the health services network, start with an assessment of the situation of the health units. This makes it possible to know such important aspects as their level of functionality or availability, as well as the aspects that need support as a higher priority. These aspects, when implementation begins, should also be part of the monitoring and evaluation work.

There are many different tools for this purpose. Some are aimed at carrying out a quick review in acute emergency or difficult access contexts to extract basic information, while others are aimed at a more complete evaluation and calculation of monitoring indicators, at evaluating other aspects such as users' opinions about these services, or at analyzing specific aspects of a health problem to guide more vertical actions. 

In the last two decades there have been efforts aimed at the development of numerous tools for the assessment of health units and their mapping in a geographic area in humanitarian contexts or for system strengthening,more or less standardized for coordinated action.

There are numerous health facility assessment tools and methods

Every humanitarian organization, practically, has developed its own tools for the assessment of health services. In fact, every professional in the sector probably has a folder on his or her computer full of lots of versions and adaptations of small questionnaires for more or less rapid assessments. All of them are usually quite similar, with minor differences resulting from continuous modifications. Even so, every time it is necessary to analyze health needs and identify a possible intervention, there is an appetite -almost irrepressible- to make a new readaptation.

Some needs assessment tools are multi-sectoral and designed for rapid use in emergencies. These include IASC's Multi-Sector Initial Rapid Assessment (MIRA), UNHCR's Needs Assessment for Refugee Emergencies (NARE), or OCHA's more recent Joint and Intersectoral Analysis Framework (JIAC 2.0).

However, in addition to this, some humanitarian health and global health actors have tried to propose complete, more or less standardized toolkits for large-scale health services assessment, mostly under a health systems strengthening framework but also with a possible early capacity recovery approach. Efforts in this direction by the World Bank, USAID and WHO are worth noting.

  • The World Bank, for example, launched in 2010 and updated in2018 its Service Delivery Indicators (SDI) questionnaires for health, very focused on assessing the quality of health services from the experience of users. However, these are complex tools posed for extensive data collection (over one to two years) at the national level.
  • USAID launched its Service Provision Assessment (SPA) proposal in 2012, developed by ICF International under the Demographic and Health Surveys project. This tool, which was again completely updated in 2022, focuses on assessing the availability and quality of specific services.
  • In parallel to these initiatives, the WHO launched its Service Availability Mapping (SAM) and later, in 2015, a new tool, developed in collaboration with USAID: the Service Availability and Readiness Assessment (SARA). which makes it possible to calculate availability and readiness indices for specific health units and health services.

There are two key health facility assessment tools today and for the future: HeRAMS and HHFA

At present, and despite the coexistence with a myriad of other tools, the two that seem to have the most potential in the future are HeRAMS and HHFA.

The Health Resources Availability Mapping System (HeRAMS) is a collaborative effort led by WHO and the Global Health Cluster that began in 2007 to enable mapping and monitoring of the availability of essential health resources and services in humanitarian settings, to help identify needs, dysfunctionalities, their causes and priorities for decision making. The result of the HeRAMS application is a Master List of health units with information on location and type of health services in a geographic area, as well as data on the general state of infrastructure and equipment, the functionality of the facility, accessibility, how it is being managed, the services it offers and the type of external support it receives.

Its implementation requires solid coordination among health sector actors around its corresponding cluster. Once the information is available it can be displayed on a dashboard or web dashboard and in reports. HeRAMS does not allow for in-depth analysis of all elements of a health system, but it allows for essential monitoring in difficult contexts that can inform decision making in humanitarian action.

In addition, in 2020, WHO launched a new initiative to harmonize the multiple existing health facility assessment tools into one: the Harmonized Health Facility Assessment (HHFA). This initiative, in which USAID and the World Bank also collaborated, culminated in 2022 and 2023 with the publication of a comprehensive set of questionnaires to assess the availability, capacity, management and financing of health units and the provision of services according to quality standards, with a strong focus on primary health care, universal health coverage and the Sustainable Development Goals.

These two tools, although they make a good tandem, cannot cover all the needs of humanitarian or global health organizations. These sometimes need more agile and lightweight tools for isolated use in specific projects, such as WASH FIT (for example), to assess water, sanitation, hand hygiene, environmental cleanliness and waste management in health facilities. However, the HeRAMS and the HHFA offer a strong basis for adaptation and, above all, for collaboration between multiple actors for common coordinated monitoring.

The opinion of health service users (and health personnel) matters

In humanitarian action, haste is the enemy of quality. When there is an emergency, rapid health services assessment actions usually prioritize the use of quantitative tools. These are usually used by health personnel who, during a visit to a health center and an interview with those in charge, complete a model questionnaire.

However, most quantitative tools focus more on the inputs and outputs of the health system and its services. After all, it's good that drugs are available, staff are well trained, the solar panel battery is working, and there are plenty of consultations, right?

When attempting to act urgently, the mistake is often made of paying little attention to the views of the people who use these services. However, they are the people affected and to whom the health system (and the humanitarian actors that support and sustain it) must be accountable. It is therefore urgent to reconsider the importance of dialoguing with these people, who are the ones who can provide the most relevant information on the effectiveness of services to solve their problems, on who is being discriminated against and without access, or on their lack of financial protection against health problems.

Health systems

NotebookLM

You can review my bibliographic references on health service delivery with this NotebookLM, an artificial intelligence-based research assistant. Do you want to know more?

How to cite this page

Abarca, B. (March 31, 2026). Health service delivery: characteristics, humanitarian crises and assessment tools. Salud Everywhere. https://saludeverywhere.com/en/health-in-humanitarian-crises/health-service-delivery/

External links

Search
Scroll to Top