Reproductive Health in Crisis

UNRWA Experiencein Occupied Palestine

Territories (OPT)

5 - 7 November 2008 Cairo

Lebanon Field – Health Department | November 2008

Objectives:Objectives:

Highlight the role of UNRWA in providing reproductive health services in OPT.

Highlight the obstacles face UNRWA in providing reproductive health services in OPT.

Highlight how UNRWA coped to deliver reproductive health services in OPT

U.N.R.W.A.U.N.R.W.A.

UnitedNationReliefWorkAgency

for Palestine Refugees in the Near East

UNRWA, was established by United Nations General Assembly resolution 302 (IV) of 8 December 1949 as a subsidiary

organ of the United Nations

Following the Arab-Israeli war in 1948, an estimated 750,000 refugees left

their homes, villages and towns, initially took shelter in temporary

camps, in mosques and schools, or in towns and villages.

International organizations, mainly the International Committee of the

Red Cross (ICRC), provided emergency assistance for the refugees until May

1950 when UNRWA started its operations

Another wave of refugees was after Arab-Israeli war in1967.

“UNRWA remains essential and stabilizing factor in all fields of operation”

UNRWA Fields of Operation

Jordan

Syria

Lebanon

W.B

Gaz

a

1,858,000

442,000

416,000

722,000

1,017,000

UNRWA

Fields of Operation

&&

Registered RefugeesRegistered Refugees

4.5 Million

(360 sq km)

UNRWA Mandate:UNRWA Mandate:

To carry out direct Relief and Works Programs for Palestine refugees. Through delivery of vital services in:

EducationHealth. Relief. Social Services. Emergency Aid.

UNRWA Health Services:UNRWA Health Services:

UNRWA's Health Programme focuses on comprehensive preventive andprimary health care.

Services cover:

Medical care. Family health

i. Child Health and school healthii. Reproductive Health (Maternal Health ,STD’s & Family

Planning services) Disease control and prevention. Health education.

All Health services are provided directly and at no cost to Palestinerefugees through the Agency's network of 128 primary health carefacilities located both inside and outside refugee camps in the five fields of operation.

Comprehensive Reproductive Health services are available in each primary health care facility.

UNRWA Challenges:UNRWA Challenges:

Poverty and unemployment on the rise which increases the demand for health services especially in oPt and Lebanon.

“IUED survey issued in July 2005, found that 1 in 3 refugees living in camps in the oPt were surviving on less than USD 1 per day”.

UNRWA Challenges:UNRWA Challenges:

Acute emergencies on top of the ongoing chronic emergencies and access barriers make health service provision difficult especially in OPt.

…. How is UNRWA coping?

The current situation in Occupied Palestine Territories (OPT)The current situation in Occupied Palestine Territories (OPT)

Restriction on freedom of movement is part of the daily life for the population of the Occupied Palestine Territories.

Restrictions take various forms:

Trenches encircling villages, curfews of variable duration and “military zones” to which all access are forbidden.

Placement of at least 540 permanent military checkpoints - a 12 per cent increase since the start of 2006.

Randomly erected temporary road blocks and physical barriers, divide the West Bank into 300 clusters and complete separation from Gaza.

Fragmentation of land by the separation wall has resulted in

even more severe restriction of movements of goods and people. OCHA 2006

540 permanent military

checkpoints

Road blocks

and

physical barriers,

divide the West Bank

into

300 clusters

Total Area5,860 sq km

Total Area5,860 sq km

Fragmentation of land by the separation wall has resulted in even more severe restriction of movements of goods and people.

. OCHA 2006

Fragmentation of land by the separation wall has resulted in even more severe restriction of movements of goods and people.

. OCHA 2006

Delivery at checkpoints:Delivery at checkpoints:

One out of a thousand pregnant women delivered while stranded at Israeli military checkpoints during labour (2005)

Delays at these checkpoints have resulted in dozens of unattended roadside births, some of which ended in deaths. “UNFPA”

Since the beginning of the Al-Aqsa Intifada in 2000, at least 68 pregnant Palestinian women gave birth at Israeli checkpoints, leading to 35 miscarriages and the death of five women.

10% of pregnant women spent 2 - 4 hours on the road before reaching a medical centre or a hospital, while 6% spent more than four hours, when the normal traveling time before the Intifada was 15-30 minutes.

This hardship is estimated to have contributed to an 8.2% increase of home deliveries.

“Palestinian Ministry of Health reports”

Delays at these checkpoints have resulted in dozens of unattended roadside births, some of which ended in deaths. “UNFPA”

Access to Health Care:Access to Health Care:

Geographical access:

The closure system in general, and the separation wall in particular, has had significant impacts on UNRWA’s ability to provide humanitarian and health assistance to the refugee community, in particular the ability of staff and health care seekers to get to facilities. In addition to the internal and external closure systems that require complex coordination procedures…

Intermittent strike:

Strike and the deterioration of public services has led to an increased demand of non MoH services

How the crises in OPT was addressed?

U.N.R.W.A.U.N.R.W.A.

How the crises was addressed:How the crises was addressed:

Mobile Health Teams: Established in the West Bank since February 2003 to meet the additional burden on the health system and to facilitate access to health services in locations affected by closures, checkpoints, and the separation wall. In spaces made available by communities or even in the street

Sustain and improve antenatal, delivery, postpartum, high quality services of F. Planning and newborn care.

combating sexually transmitted infections and other gynecological morbidity through an integrated surveillance system, providing medications, condoms and counseling.

“Cont…..

How the crises was addressed “cont..”How the crises was addressed “cont..”

• Partnerships and cooperation: To overcome limitations posed by limited financial resources, staff shortage, overwork and limited secondary and tertiary care, UNRWA developed an efficient system of cooperation and complementation with other health care providers in the field (MOH- PRCS, NGOs etc…)

• Community empowerment; Staff providing services are usually selected from the community and they are living with the community during curfews and closures.

• Maintained an emergency referral systems in coordination with other health care providers and the community.

• Ambulances were provided with adequate delivery kits in addition to other life support equipment to assist delivery at check points.

“Cont…..

How the crises was addressed “cont..”How the crises was addressed “cont..”

• Establishment of 12 maternity units inside camps equipped to assist normal delivery and supported with efficient referral and emergency care.

These Units offer reproductive health and emergency obstetric care as well as psychosocial counseling.

These services enabled health providers and midwives to more effectively administer safe deliveries in their respective communities and provide care for mothers and newborns afterwards.

• Integration of Specialist care :covering paediatrics, obstetrics, gynaecology and cardiology into a wide net of primary health care centres.

• Upgrading the capacity of the Only hospital run by UNRWA in WB (Qalquilia Hospital from 45 to 63 beds)

• Other partners supported the upgrading of maternity wards, operating theatres and referral mechanisms in six hospitals in the West Bank and Gaza, which account for more than 60 per cent of deliveries and represent the major referral centers in six governorates.

“Cont…..

How the crises was addressed “cont..”How the crises was addressed “cont..”

• Establishment of new health centers to cope with the increase demand and to serve pockets of un-served and isolated populations. The established centers provide reproductive health services in addition to other preventive and curative health services.

• A well established MCH health information systems at different levels, including service delivery level coupled with the updating of management guidelines and decentralize management to better respond to the needs of the refugees.

• Specific supplementary feeding programmes including distribution of food baskets, iron and vitamin A supplementation and fortification of flour,

Factors Contributed to Success

U.N.R.W.A.U.N.R.W.A.

Ensure quality of care.

Technical and financial support from the international community, other UN agencies (WHO, UNICEF, UNFPA….)

International support was crucial to provide immunity and facilitate mobility and access of ambulances.

Sustainable strategies that strengthen the health care system were developed and implemented.

“cont…”

Factors contributed to success “cont…”Factors contributed to success “cont…”

Community participation and Health staff dedication . Health service research to identify programme deficiencies and to

provide with evidence-based management to improve performance.

The highly acceptable MCH services were utilized as the entry point for a large number of programs and effective interventions such as family planning, gender based violence, sexual health and screening.

Advocacy and capacity to disseminate information and gain support.

Raising community awareness on the availability of the newly established services at various centers.

Health personnel continuing education and training to maintain technical excellence and meet future needs.

Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)

Identify an organization (s) and individuals responsible for coordinating the MISP

Prevent and manage the consequence of sexual violence

Reduce HIV transmission Prevent excess neonatal and maternal

mortality and morbidity Plan for the provision of comprehensive

RH services

Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)

Identify an organization(s) and Identify an organization(s) and individuals responsible for individuals responsible for coordinating the MISPcoordinating the MISP

UNRWA in partnership with UNRWA in partnership with MOH, UN Organizations and MOH, UN Organizations and NGOs coordinated the process NGOs coordinated the process each in the area of responsibility. each in the area of responsibility.

Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)

Prevent and manage the consequence Prevent and manage the consequence of sexual violenceof sexual violence Reporting system is in place at all UNRWA service

delivery points. Management and Counseling of victims.

Health services able to manage cases

Emergency Contraceptives (within 7days) (Available)

Post Exposure Prophylaxis (PEP) for HIV/AIDS (72hours) (Not Available)

Hepatitis B vaccination (Available) Presumptive treatment for STIs (Available) Tetanus toxoid and tetanus immunoglobulin

(Available)

Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)

Reduce HIV transmissionReduce HIV transmission

Implementation of Universal Precautions

Staff understand and practice universal precautions; clean health facility; reduce unnecessary procedures; use protective barriers (disposable gloves); use disposable syringe and needle (sharp management system); have incinerator and sterilization facilities

Provide safe blood transfusions

Blood transfusions provided in health facilities where laboratory facilities exist to

screen donors for HIV and other infection, to cross-match blood and to manage

complications due to blood transfusions.

Condoms are available in all health facilities for free

Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)

Prevent excess neonatal and maternal Prevent excess neonatal and maternal mortality and morbiditymortality and morbidity

Activities

Clean delivery kits for pregnant women including Neonatal resuscitation kit ,provided by different partners, distributed to

Maternity units Health facilities Ambulances

Referral system for Obstetric and neonatal emergencies organized and well established between different health service providers to ensure that there is quality emergency obstetrics and neonatal service at the referral center

Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)Minimum Initial Services Package (MISP)

PPlan for the provision of lan for the provision of comprehensive RH servicescomprehensive RH services

Reproductive Health services are available in each primary health care facility.

Safe Motherhood, including emergency obstetric care.

Family Planning. STI/HIV. Monitoring and Surveillance.

THANK YOU.