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

Page updated onApril 25, 2026

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.

Table of contents:

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 series of key characteristics (WHO, 2010)World Health Organization. (2010). Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies. World Health Organization. https://iris.who.int/handle/10665/258734:

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 relieving a health problem, safe for patients, and delivered in a timely manner without long waiting times. Ultimately, quality must be understood from the perspective of the people who use (or decide not to use) these services (WHO et al., 2018)World Health Organization, Organisation for Economic Co-operation and Development, & World Bank. (2018). Delivering quality health services: A global imperative for universal health coverage. World Bank. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/482771530290792652/delivering-quality-health-services-a-global-imperative-for-universal-health-coverage.

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 emergencies and complex humanitarian crises, the health system and service delivery can collapse. When this occurs, the health system loses the capacity to secure the resources necessary for the delivery of the usual package of services. Health workers are forced to abandon their posts, infrastructure is damaged and equipment maintenance declines, medicine supply is disrupted, referral and counter-referral systems weaken, and the population's access to services becomes more difficult — particularly for those who are displaced or trapped in areas of high insecurity (WHO, 2020)World Health Organization. (2020). Quality of care in fragile, conflict-affected and vulnerable settings: Taking action. World Health Organization. https://www.who.int/publications/i/item/9789240015203.

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 in order to adapt and define a new essential health services package. This will make it possible to address the most important health problems. This package of interventions must cover both preventive and curative, rehabilitation, and palliative services, across different levels of care (WHO, 2024)World Health Organization. (2024). Preliminary guidance for a package of high-priority health services for humanitarian response (H3 package). World Health Organization. https://iris.who.int/handle/10665/378158. Services must be available to all people, with good quality. They should therefore be provided without direct costs to 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 an essential health services package is, however, no easy task (Global Health Cluster, 2018)Global Health Cluster. (2018, February 15). Working paper on the use of essential packages of health services in protracted emergencies. World Health Organization. https://healthcluster.who.int/publications/m/item/working-paper-on-the-use-of-essential-packages-of-health-services-in-protracted-emergencies. 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. Furthermore, to ensure it does not remain a mere utopian aspiration, its feasibility and potential costs must be analysed in settings where resources are scarce and often not guaranteed. Some services may require medicines not found in standard inter-agency kits or specialised training of health workers (Griekspoor et al., 2026)Griekspoor, A., Kampalath, V. N., Broccoli, M. C., Fogarty, J., Pasha, E., Zunong, N., Blanchet, K., & Reynolds, T. (2026). The development of the H3 Package: A package of high-priority health services for humanitarian response. BMJ Global Health, 11(1), e020120. https://doi.org/10.1136/bmjgh-2025-020120.

New actors and health service delivery modalities become necessary

Humanitarian actors must help ensure that the affected population has access to the health services it needs. It is recommended to set a target of 80% of the population having access to primary healthcare services on foot (no more than one hour's walk) and 80% of facilities offering priority services. To achieve this, a sufficient network of health facilities at different levels must be guaranteed and maintained, and external support needs for these services must be identified.

When this is not feasible or proves insufficient, alternative temporary service delivery mechanisms emerge. The most common involves deploying emergency medical teams or mobile clinics (WHO, 2021)World Health Organization. (2021). A guidance document for medical teams responding to health emergencies in armed conflicts and other insecure environments (the red book). World Health Organization. https://www.who.int/publications/i/item/9789240029354. These teams may operate under existing public facilities, which deploy them to reach populations unable to access static health services. In other cases they are operated by humanitarian organisations, which step in to temporarily cover a fundamental need, but with a risk of fragmentation. They may have service packages different from the pre-existing one, different payment arrangements (generally with no direct cost to users), independent information systems (which can hinder continuity of care for populations on the move), and sometimes significant quality differences compared to what previously existed (ICRC, 2006)International Committee of the Red Cross. (2006). Mobile health units: Methodological approach. https://www.icrc.org/en/publication/0886-mobile-health-units-methodological-approach.

Since 2010, efforts have been made to systematise and establish minimum standards for Emergency Medical Teams, both national and international (WHO, 2021)World Health Organization. (2021). Classification and minimum standards for emergency medical teams (the blue book). World Health Organization. https://www.who.int/publications/i/item/9789240029330, as well as initiatives to improve their quality (Global Health Cluster, 2026)Global Health Cluster. (2026). The mobile clinic quality of care toolkit for humanitarian settings. World Health Organization. https://healthcluster.who.int/our-work/task-teams/quality-improvement-task-team/mobile-clinics-toolkit.

This has facilitated to some extent their deployment and coordination and, therefore, the governance of the health system during the crisis, despite the multiplicity of actors. Depending on how they are carried out, these humanitarian interventions can minimise 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 in 2018 its Service Delivery Indicators (SDI) questionnaires for health, which are heavily focused on evaluating the quality of health services from the perspective of users. However, these are complex tools designed for extensive data collection (over one or two years) at the national level (World Bank, 2018)World Bank. (2018). Service Delivery Indicators (SDI) health surveys. https://www.worldbank.org/en/programs/service-delivery-indicators/health.
USAID launched its Service Provision Assessment (SPA) proposal in 2012, developed by ICF International within the framework of the Demographic and Health Surveys project. This tool, which was fully updated again in 2022, focuses on assessing the availability and quality of specific services (USAID, 2022)USAID. (2022). Service Provision Assessments (SPA). DHS Program. https://dhsprogram.com/Methodology/Survey-Types/SPA.cfm.
In parallel with these initiatives, WHO launched its Service Availability Mapping (SAM) and subsequently, in 2015, a new tool developed in collaboration with USAID: the Service Availability and Readiness Assessment (SARA), which allows availability and readiness indices to be calculated for health facilities and specific health services (WHO, 2015)World Health Organization. (2015). Service Availability and Readiness Assessment (SARA). https://www.who.int/data/data-collection-tools/service-availability-and-readiness-assessment-(sara).

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 the mapping and monitoring of the availability of essential health resources and services in humanitarian contexts, helping to identify needs, dysfunctions, their causes, and priorities for decision-making. The result of applying HeRAMS is a Master List of health facilities with information on the location and type of health services in a geographical area, as well as data on the general state of infrastructure and equipment, facility functionality, accessibility, how it is being managed, the services it offers, and the type of external support it receives (WHO, n.d.)World Health Organization. (n.d.). HeRAMS: Health Resources and Services Availability Monitoring System. https://www.who.int/initiatives/herams.

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.

Furthermore, in 2020 WHO launched a new initiative to harmonise the multiple existing health service 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 complete set of questionnaires that allows the assessment of the availability, capacity, management, and financing of health facilities and service provision in accordance with quality standards, with a strong focus on primary healthcare, universal health coverage, and the Sustainable Development Goals (WHO, 2022)World Health Organization. (2022). Harmonized Health Facility Assessment (HHFA). https://www.who.int/data/data-collection-tools/harmonized-health-facility-assessment.

These two tools, while forming a good combination, cannot cover all the needs of humanitarian or global health organisations. These sometimes require more agile and lightweight tools for standalone use in specific projects, such as WASH FIT, for example, to assess water, sanitation, hand hygiene, environmental cleaning, and waste management in health facilities (WHO & UNICEF, 2022)World Health Organization & UNICEF. (2022). WASH FIT: Water and sanitation for health facility improvement tool (2nd ed.). https://www.washinhcf.org/resource/wash-fit-2/. Nevertheless, HeRAMS and HHFA offer a strong foundation for adaptation and, above all, for collaboration among multiple actors towards coordinated joint 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.