Leveraging global and grassroots expertise to improve access to sexual and reproductive health services in humanitarian emergencies

Over the past decade, there has been growing agreement among international, national and local humanitarian actors that much more must be done to ensure access to essential sexual and reproductive health (SRH) services in emergency responses. There are currently 32 million girls and women of reproductive age affected by humanitarian emergencies, OCHA, Global Humanitarian Overview 2017 (https://www.unocha.org/sites/dms/Documents/GHO_2017.pdf) who face increased risks of multiple forms of gender-based violence (GBV), unintended pregnancy, maternal morbidity and mortality, sexually transmitted infections (STIs) including HIV, and unsafe abortion. Research from multiple humanitarian settings shows that up to 40% of women experiencing forced displacement want to avoid becoming pregnant in the next two years. T. McGinn et al., ‘Family Planning in Conflict: Results of Cross-sectional Baseline Surveys in Three African Countries’, Conflict and Health, 5:11, 2017 (www.conflictandhealth.com/content/5/1/11)  Taken together, these realities have pushed advocates and policy-makers to champion SRH services as a priority in humanitarian action.

To help drive progress, organisations at all levels are documenting solutions and developing guidance for improving access to SRH services in humanitarian emergencies. At the international level, the humanitarian community has developed and vetted standards and guidelines for the provision of SRH services in the Inter-Agency Service Field Manual for Reproductive Health Services in Humanitarian Emergencies (IAFM). See http://iawg.net/iafm/. At the same time, many local and national first responders – including women- focused CSOs, health providers and community-based clinics in protracted crisis settings – have worked for years to provide safe and inclusive access to SRH services. In many contexts, these grassroots organisations have built unparalleled trust and understanding with local communities, enabling them to deliver SRH services effectively.

Mainstreaming and applying international and local expertise on SRH remains a challenge, and a 2014 assessment found that SRH services were still unavailable at the onset of many humanitarian responses. Inter-Agency Working Group on Reproductive Health in Crisis, Taking Stock of Reproductive Health in Humanitarian Settings: Key Findings from the IAWG on Reproductive Health in Crises’ 2012–2014 Global Evaluation, 2014 (http://iawg.net/ wp-content/uploads/2016/08/IAWG-GE-Summary_English.pdf). Within many international organisations, leadership and relevant field-based teams are not sufficiently knowledgeable on the IAFM, and more training is needed to build capacity in this area. At the same time, the expertise of local and national responders is still largely overlooked – a missed opportunity to invest in effective grassroots solutions.

Addressing these problems requires supporting and building expertise on SRH at the global and grassroots levels. To that end, this article highlights key opportunities for supporting both global and grassroots expertise to drive more concrete action on SRH in emergencies – and outlines what still needs to be done to create real change.

Utilising global guidance on providing SRH services at the onset of emergencies

Respected global guidance on providing SRH services in emergencies exists in the IAFM – and, when fully funded and implemented, can be lifesaving for girls and women in humanitarian settings. The IAFM offers authoritative guidance on how to provide reproductive health services at every stage of a humanitarian emergency, including in the critical first 48 hours. The guidance was released in 1999 as a tool to help humanitarian practitioners plan, implement and evaluate SRH services, in refugee situations specifically. In 2010, the Inter-Agency Working Group on Reproductive Health in Emergencies (IAWG) – a broad- based coalition that works to expand and strengthen access to SRH services in crises – published a new edition to encompass the SRH needs of people affected by all forms of humanitarian emergencies.

Since 2010, evaluations of the IAFM have found that, despite increased funding, awareness and ability to deliver SRH services in humanitarian settings, significant gaps remain. In particular, practitioners have explicitly requested more guidance and assistance in providing adolescent SRH services, comprehensive contraceptive methods, abortion care, emergency obstetric and newborn care and addressing sexual violence. Ibid.

In response, IAWG led a collaborative two-year revision process that used this feedback to inform the 2018 revision of the IAFM. In addition to sharing documented evidence and best practices for the challenges mentioned above, the 2018 IAFM also up- dated the Minimal Initial Service Package (MISP) – a list of crucial actions to respond to reproductive health needs at the early stages of a humanitarian emergency. These include:

• Enhancing leadership: guidance for the health sector/ cluster to identify an organisation to lead implementation of the MISP, and what their responsibilities will entail to ensure successful MISP implementation. This includes hosting regular meetings to coordinate activities, reporting back to relevant clusters, mapping existing services and ensuring community awareness of SRH services.
• Addressing sexual violence: best practices for prevent- ing sexual violence and responding to the needs of survivors, including ensuring preventative measures are in place to protect affected populations, making clinical care and referral services available and creating safe spaces in health facilities to support survivors.
• Preventing transmission and reducing morbidity and mortality due to HIV and other STIs: establishing safe blood transfusion, access to condoms, provision of anti-retrovirals and other treatments and ensuring that STI diagnosis and treatment services are available in health facilities.
• Preventing excess and maternal and newborn morbidity and mortality: ensuring access to clean and safe delivery spaces, obstetric care services and newborn health services and supplies; establishing round-the- clock referral systems from community clinics to health centres and hospitals; ensuring that post-abortion care is available; and ensuring access to clean delivery supplies when access to a health facility is not possible.
• Preventing unintended pregnancy: ensuring the availability of a range of contraceptive methods at primary health facilities; improving access to comprehensive SRH information; and promoting community awareness of the availability of contraceptives.
• Planning for comprehensive SRH services: services are integrated into primary healthcare.
• Providing safe abortion care: the updated MISP also emphasises the need for safe abortion care in health centres and hospitals, provided to the fullest extent allowable under the law of the country where the MISP is being implemented.

However, the IAFM and MISP are ultimately just words on paper – and challenges related to funding, staff capacity and community engagement still impede real action. For example, while humanitarian funding for SRH activities generally increased between 2009 and 2013, it was still only 43% of what was requested Ibid. . Additionally, there is an urgent need to build institutional capacity within international, national and local organisations to better understand and implement the IAFM and MISP when it matters most. This includes capacity strengthening around commodity management to prevent stock-outs of essential SRH supplies during crises and ensure a smooth transition from the MISP to comprehensive SRH services in the recovery phase. Finally, much more must be done to provide technical assistance to national and community- based organisations on the MISP, to ensure SRH services are appropriate to local contexts and can be sustained after international actors leave.

Evidence shows that, when the IAFM and MISP are effectively implemented and backed by good funding, skilled staff and meaningful community engagement, the effects can be life- saving. The following case study from the International Rescue Committee (IRC)’s work to utilise the MISP in Cox’s Bazar, Bangladesh, is one example.

MISP implementation in Cox’s Bazar, Bangladesh

Nearly 700,000 Rohingya refugees have fled to Cox’s Bazar in Bangladesh – adding to the 300,000 already living in the area, having fled previous waves of violence in Myanmar. Girls and women have been exposed to extremely high levels of violence, sexual assault and rape, and have very limited, if any, access to health services – both before and after displacement. Experienced emergency responders were urgently needed, particularly in GBV and SRH, as well as effective coordination and collaboration among different actors on the ground.

The IRC’s SRH emergency coordinator was deployed to Cox’s Bazar to ensure the availability of contraception, screening and treatment for STIs, clinical care for sexual assault survivors, safe delivery and emergency obstetric care – essential components of the MISP. The IRC also partnered with and provided technical support for RTMI, a local NGO, to set up comprehensive women’s centres to provide a package of essential services. With these comprehensive centres in place, the IRC and RTMI ensured girls’ and women’s access to lifesaving protection and SRH services, while responding to the needs of GBV survivors in a safe, dignified and confidential manner.

In the space of just two months, 421 contraceptive methods were distributed and 427 clients received psychosocial counselling. The IRC and its partners have since moved beyond implementing the MISP to providing comprehensive SRH services, including basic emergency and neonatal care, post- abortion care and menstrual regulation. Through this work, the IRC has demonstrated that providing SRH services is feasible, even in the most complex environments, especially through collaborations with local experts like RTMI.

Supporting grassroots expertise to ensure sustainable SRH services

As the IRC case demonstrates, grassroots organisations have an essential role to play in expanding access to SRH services in emergencies and in their aftermath. To maximise impact, strengthening and investing in the existing expertise of grass- roots organisations must begin before emergencies strike.

This is particularly true in places where humanitarian emergencies have been frequent or cyclical. For example, countries like Uganda, Lebanon, Jordan, Serbia and Colombia have hosted refugees and internally displaced people affected by more than one crisis; others, like Haiti, the Philippines and Tonga, have experienced cyclical natural disasters. Enhancing preparedness and resilience is critical to ensuring that communities are equipped to respond to these crises and recover more quickly.

When it comes to SRH, this means ensuring services are integrated in primary healthcare systems and national plans for risk reduction and emergency response. Sneha Barot, ‘In a State of Crisis: Meeting the Sexual and Reproductive Health Needs of Women in Humanitarian Situations’, Guttmacher Policy Review, 20, 2017 (www.guttmacher.org/gpr/2017/02/state-crisis-meeting-sexual-and- reproductive-health-needs-women-humanitarian-situations). This requires continuous training and supervision of healthcare providers to make sure that they have the skills, supplies and resources they need to deliver safe, inclusive and non-discriminatory access to SRH services, including to girls and women in disaster-prone areas. When emergencies strike, recruiting skilled and trained SRH providers is challenging, so investing in local capacity strengthening before emergencies occur can help mitigate this.

Integrating SRH in preparedness and resilience efforts also requires identifying and investing in local and national women- focused organisations that are already providing SRH services. However, there’s still a long way to go. Globally, only 3% of humanitarian aid was directed to local and national organisations in 2017 – and even less to those focused on girls and women – a massive missed opportunity to build capacity among local actors who know the context and entry points to deliver SRH services most effectively. Development Initiatives, Global Humanitarian Assistance Report 2018, 2018 (http://devinit.org/post/global-humanitarian-assistance-report-2018/).  Identifying and investing in these organisations as part of broader preparedness activities can help ensure they have the resources they need to extend their services to crisis-affected populations quickly. In Lebanon, organisations like Marsa Sexual Health Center fill crucial gaps in government health provision by providing free and low-cost sexual health services and information inclusive of LGBTQIA+ communities, sex workers, undocumented migrants and Palestinian refugees.

Marsa Sexual Health Center in Lebanon

A Beirut-based non-profit organisation, Marsa provides essential sexual health services and information to a rapidly growing client load. Programmes emphasise respect, privacy and confidentiality. Marsa’s safe and inclusive approach to providing SRH services means it is well-placed to extend SRH services to other marginalised communities, including girls and women, young people and Syrian and Palestinian refugees, who also often face stigma and discrimination. Through their work, the team at Marsa have demonstrated the wide reach and impact a local organisation can have. It has provided voluntary counsel- ling and rapid HIV testing to more than 12,500 clients and subsidised medical consultations for another 4,195 clients, and psychosocial counselling and alternative therapies for 2,000 clients.

Even with their considerable reach, the team at Marsa know that one Beirut-based health clinic cannot accommodate the SRH needs of all who seek these services in Lebanon, including the over one million registered Syrian refugees in the country. A situational analysis conducted by the Center found that many medical and nursing staff in Lebanon still lack knowledge on SRH, and the skills to provide these services in a stigma-free environment – which is particularly important for LGBTQIA+ and refugee populations, who are already highly stigmatised.

To that end, the team have worked to share their expertise in providing safe, inclusive and non-discriminatory SRH services with other health providers. The Center began offering vocational training for family medicine and dermatology residents around SRH, training 50 so far. To address  the lack of information on sexual heath in medical and nursing schools’ curricula, Marsa also launched a project called Inc!te in three Lebanese universities, which aims to positively change the attitudes of healthcare providers towards sexuality and sexual practices.

Marsa plans to provide training for other centres in the region on its activities. It is also hoping to produce a best practice manual for SRH in complex environments in the Middle East and North Africa. However, limited donor funding for SRH activities makes it difficult to bring this work to scale, and poor access to flexible and long-term funding opportunities for local organisations working on SRH stifles Marsa’s ability to plan for the future.

Promoting learning and evidence-building around SRH takes time, particularly when working in contexts like Lebanon, where sex and sexuality are taboo. To support local and national organisations to scale up direct services to refugees, contribute to scientific evidence, and build a basis for advocacy, more flexible and sustainable funding is critically needed.

Conclusion

If one thing is clear, though, it is that enhancing access to SRH services in humanitarian settings requires leveraging and supporting the expertise of humanitarian actors at all levels. At the local and national levels, this includes supporting local women-focused CSOs, health providers and broader national health systems to deliver comprehensive SRH services before, during and after emergencies. At the global level, this means ensuring that international humanitarian organisations and UN agencies have the knowledge, resources and funding to fully implement actions outlined in the IAFM and MISP, without delay or interruption.

Between local, national and global actors, we have the critical guidance and knowledge we need to increase access to sexual and reproductive health services in humanitarian emergencies. It’s time to put money, resources and concerted action behind that expertise.

Marcy Hersh is Senior Manager for Humanitarian Advocacy at Women Deliver. Diana Abou Abbas is Executive Director of the Marsa Sexual Health Center.