Consultation on Reproductive Health Technologies for Crisis Settings Consultation on Reproductive Health Technologies for Crisis Settings May 2008 Seattle, Washington Sandra Krause, Director Reproductive Health Program Women’s Commission for Refugee Women and Children

Who are Populations in Crisis? l 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. l 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 Populations 1. Sudan (including Darfur) million 2. Iraq million 3. Colombia million 4. Former Palestine million 5. Afghanistan million 6. Democratic Republic of Congo million 7. Uganda million

Rwanda Genocide 1994 Rwanda Genocide

Early Days of Crisis Situations

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

RHR Inter-agency Field Manual

Four technical areas of RH: l Safe Motherhood including emergency obstetric care l Family Planning l STIs/HIV/AIDS l Gender-based violence

Minimum Initial Service Package (MISP) l Minimum l Initial l Service l Package l Basic, limited RH l for use in emergencies, without site-specific needs assessment l services to be delivered to the population l supplies and activities, coordination and planning

Objectives of the MISP l Identify an organization or individual to facilitate the coordination and implementation l Prevent and manage the consequences of sexual violence l Reduce HIV transmission l Prevent excess neonatal and maternal morbidity and mortality l Plan for comprehensive RH services

Reproductive Health Kits 1). Interagency Reproductive Health Kits l Provides the material resources to implement the MISP l Designed for three months l Comprises 12 kits l Can be ordered from UNFPA 2). Interagency Emergency Health Kit l Formerly the New Emergency Health Kit (NEHK) l Designed by WHO, UNHCR, UNICEF, UNFPA, MSF ICRC/IFRC l 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 Crisis l Women’s Commission, Refugee Women and Reproductive Health Care: Reassessing Priorities (1994) l Sexual violence associated with genocide in Rwanda and Bosnia Hercegovina l International Conference on Population and Development (1994) l Reproductive Health for Refugees Consortium (1995) l Inter-Agency Working Group on Reproductive Health in Refugee Situations (1995)

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

Terms of Reference for RH Coordinator / Focal Point (1) l Be focal point for RH services and provide technical assistance to refugees and agencies l Liaise with national and regional authorities l Liaise with other sectors to ensure a multi- sectoral approach to RH issues l Create/adapt and introduce standardized strategies for RH – integrated with PHC

Terms of Reference for RH Coordinator / Focal Point (2) l Initiate and coordinate information sharing sessions l Introduce standardized protocols l Develop or adapt and introduce RH monitoring forms l Report regularly to health coordination team

Prevent and manage sexual violence l Systems to prevent violence are in place n Women have their own registration cards n Safe access to food (distributed to women), fuel (firewood), water and latrines n Women participate in the decisions that affect them n Code of Conduct against sexual abuse and exploitation in place with reporting mechanisms (protection officer) l Health services able to manage women surviving sexual violence

The MISP only includes sexual violence – not all forms of gender-based violence

Reduce maternal and neonatal morbidity and mortality l Referral system to manage obstetric emergencies *follow up to ensure referral facility is prepared for emergencies l Midwife delivery kits available for clean and safe deliveries at the health facility l Clean delivery kits for mothers or birth attendants for clean home deliveries

Planning for comprehensive RH services l Data collection, including maternal, infant and child mortality l Identification of sites for future RH service delivery l Assessment of staff capacity and ordering supplies

What the MISP is NOT l Reproductive health assessment l Ante and post-natal care l Family planning l Comprehensive RH services l All forms of gender-based violence l Training of staff (TBAs, CHWs, midwives) l Sensitization campaign for condom distribution

The Emergency Response l Comprehensive RH diverts attention from priority RH and other priority needs in an emergency

SPHERE Guidelines Integrated into 2000 versionStandard in 2004

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

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

Global Response l IAWG MISP Working Group n MISP Coordinator Job Description n Sample proposal n Integrate the MISP in complex emergency courses

Global Response l MISP Distance Learning Module n Published in September 2006 n Available in multiple languages n Certificate of completion – pass online post-test n Verifies 3.5 continuing education credits for US nurses MISP Partnership Training

Conclusion  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 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