Consultation on Reproductive Health Consultation on Reproductive Health Technologies for Crisis SettingsTechnologies for Crisis Settings

13-14 May 2008Seattle, Washington

Sandra Krause, DirectorReproductive Health ProgramWomen’s Commission for Refugee Women and Children

Who are Populations in Who are Populations in Crisis? Crisis?

Thirty-five million people live in the world as refugees and internally displaced persons, uprooted from their homes by armed conflict, persecution and natural disasters.

A refugee has crossed an international border; an internally displaced person has fled her home but is still in her own country.

Origin of Major Refugee and Displaced Origin of Major Refugee and Displaced PopulationsPopulations

1. Sudan (including Darfur)....................6 million

2. Iraq...............................................3.8million

3. Colombia ................................3.2 million

4. Former Palestine....................3 million

5. Afghanistan......................2.3 million

6. Democratic Republic of Congo.......2.1 million

7. Uganda........................1.7 million

Rwanda Genocide 1994Rwanda Genocide 1994

Rwanda Genocide

Early Days of Crisis SituationsEarly Days of Crisis Situations

Emergency/CrisisEmergency/Crisis

UNHCR: “Any situation in which the life or well-being of refugees will be threatened unless immediate and appropriate action is taken and which demands and extraordinary response and exceptional measures”

WHO and Centers for Disease Control: “Crude mortality is > 1 death per 10,000 people per day.”

RHRRHRInter-agency Inter-agency Field ManualField Manual

Four technical areas of RH:Four technical areas of RH:

Safe Motherhood including emergency obstetric care

Family Planning

STIs/HIV/AIDS

Gender-based violence

Minimum Initial Service Package (MISP)Minimum Initial Service Package (MISP)

Minimum

Initial

Service

Package

Basic, limited RH

for use in emergencies, without site-specific needs assessment

services to be delivered to the population

supplies and activities, coordination and planning

Objectives of the MISPObjectives of the MISP

Identify an organization or individual to facilitate the coordination and implementation

Prevent and manage the consequences of

sexual violence Reduce HIV transmission Prevent excess neonatal and maternal

morbidity and mortality Plan for comprehensive RH services

Reproductive Health KitsReproductive Health Kits

1). Interagency Reproductive Health Kits Provides the material resources to implement

the MISP Designed for three months Comprises 12 kits Can be ordered from UNFPA2). Interagency Emergency Health Kit Formerly the New Emergency Health Kit

(NEHK) Designed by WHO, UNHCR, UNICEF,

UNFPA, MSF ICRC/IFRC Includes: EC, PEP, materials for universal

precautions, midwifery kit

RH kits delivered to the field

Clean delivery kit contents

Brief History and Evolution of RH in CrisisBrief History and Evolution of RH in Crisis Women’s Commission, Refugee Women and

Reproductive Health Care: Reassessing Priorities (1994)

Sexual violence associated with genocide in Rwanda and Bosnia Hercegovina

International Conference on Population and Development (1994)

Reproductive Health for Refugees Consortium (1995) Inter-Agency Working Group on Reproductive Health

in Refugee Situations (1995)

Overall Goal of MISPOverall Goal of MISP

To reduce mortality and morbidity, particularly among women and girls in the initial phase of an emergency.

Terms of Reference for Terms of Reference for RH Coordinator / Focal Point (1)RH Coordinator / Focal Point (1)

Be focal point for RH services and provide technical assistance to refugees and agencies

Liaise with national and regional authorities Liaise with other sectors to ensure a multi-

sectoral approach to RH issues Create/adapt and introduce standardized

strategies for RH – integrated with PHC

Terms of Reference for Terms of Reference for RH Coordinator / Focal Point (2)RH Coordinator / Focal Point (2)

Initiate and coordinate information sharing sessions

Introduce standardized protocols Develop or adapt and introduce RH

monitoring forms Report regularly to health coordination

team

Prevent and manage sexual violencePrevent and manage sexual violence

Systems to prevent violence are in place Women have their own registration cards Safe access to food (distributed to women), fuel

(firewood), water and latrines Women participate in the decisions that affect them Code of Conduct against sexual abuse and

exploitation in place with reporting mechanisms (protection officer)

Health services able to manage women surviving sexual violence

The MISP only includes The MISP only includes sexual violence – not all forms of sexual violence – not all forms of

gender-based violencegender-based violence

Reduce maternal and neonatal Reduce maternal and neonatal morbidity and mortalitymorbidity and mortality

Referral system to manage obstetric emergencies *follow up to ensure referral facility is prepared for emergencies

Midwife delivery kits available for clean and safe deliveries at the health facility

Clean delivery kits for mothers or birth attendants for clean home deliveries

Planning for comprehensive RH Planning for comprehensive RH servicesservices

Data collection, including maternal, infant and child mortality

Identification of sites for future RH service delivery

Assessment of staff capacity and ordering supplies

What the MISP is NOTWhat the MISP is NOT

Reproductive health assessment Ante and post-natal care Family planning Comprehensive RH services All forms of gender-based violence Training of staff (TBAs, CHWs, midwives) Sensitization campaign for condom

distribution

The Emergency ResponseThe Emergency Response

Comprehensive RH diverts attention from priority RH and other priority needs in an emergency

SPHERE GuidelinesSPHERE Guidelines

Integrated into 2000 version Standard in 2004

MISP AssessmentsMISP Assessments

Pakistan, 2003Pakistan, 2003 Chad, 2004Chad, 2004 Indonesia (tsunami) 2005Indonesia (tsunami) 2005 Uganda 2006Uganda 2006 Jordan 2007Jordan 2007

FindingsFindingsResearch shows Research shows humanitarian actors are humanitarian actors are generally not familiar with generally not familiar with the MISP and it is not being the MISP and it is not being implemented at the onset implemented at the onset of an emergency. of an emergency.

Global ResponseGlobal Response

IAWG MISP Working Group MISP Coordinator Job Description Sample proposal Integrate the MISP in complex emergency courses

Global ResponseGlobal Response

MISP Distance Learning Module Published in

September 2006 Available in multiple

languages Certificate of

completion – pass online post-test

Verifies 3.5 continuing education credits for US nurses

MISP Partnership Training

ConclusionConclusion The MISP is a coordinated set of priority activities for

implementation in the early days and weeks of a crisis.

The MISP reduces morbidity, mortality and disability particularly among women and newborns. It also sets the stage from establishing more comprehensive RH services as the situation stabilizes.

Although the MISP is a well established standard of care it is not systematically implemented in crisis situations.

What can you do to improve RH in What can you do to improve RH in Crisis?Crisis?

• Humanitarian actors, donors, policy makers and others could: get certified in the distance learning

module today submit and review proposals and budgets

to ensure the MISP is included in all health sector proposals

Fund the MISP Ensure there is a overall RH coordinator in

all new emergencies and an RH focal point in every agency working in the health sector

Women’s Commission for Refugee Women and Children

www.womenscommission.org