In conflict-affected settings, the impact of displacement, violence and poor social and demographic indicators all contribute to poor health outcomes for displaced people, as well as, often, for host communities. A report by Physicians for Human Rights, for instance, indicates that over 50% of Sierra Leonean women experienced sexual violence during the conflict there. In Colombia, violence and displacement are leading to an increase in unsafe abortions, while in IDP camps in Sri Lanka, births are less well-spaced and with worse outcomes than they were before displacement.
In the early 1990s, a number of factors focused global attention on the reproductive health status of refugees and displaced populations. The crises in the former Yugoslavia and Rwanda heightened awareness of the specific reproductive health needs of refugee women. In 1994, the Womens Commission for Refugee Women and Children published Refugee Women and Reproductive Health Care: Reassessing Priorities, which highlighted the increased health risks women face in refugee settings. The report concluded that many aspects of reproductive health care were seriously neglected, including family planning information and services, AIDS education and prevention, the diagnosis and treatment of sexually-transmitted diseases and treatment of unsafe abortion. The report called for increased international attention to the provision of full reproductive health services. Shortly after its publication, the International Conference on Population and Development convened in Cairo.
A huge unmet need
The Cairo conference was the first held by the UN to officially recognise the reproductive health needs of refugees. According to the Programme of Action adopted at the conference, In planning and implementing refugee assistance activities, special attention should be given to the specific needs of refugee women and refugee children. Refugees should be provided with access to adequate accommodation, education, health services, including family planning. A central achievement of the conference was its promotion of a comprehensive approach to meeting peoples reproductive health needs. The Programme of Action calls for comprehensive reproductive health services, designed with the involvement of women, to serve womens needs and advance womens rights:
“Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.”
As a result of the conference, the Inter-Agency Symposium on Reproductive Health in Refugee Situations, comprising representatives of NGOs, academia and the UN, was convened by UNHCR and UNFPA. In preparation for the symposium, which took place in June 1995, three preparatory meetings were convened. During these meetings, participants identified what they considered to be the essential technical components of reproductive health in refugee situations:
- safe motherhood;
- family planning;
- measures to combat sexually-transmitted diseases, including HIV and AIDS;
- initiatives to tackle sexual and gender-based violence; and
- abortion services.
To accomplish its overall objective of institutionalising reproductive health in refugee situations, participants decided that drafting a refugee-specific field manual, covering the technical components they had identified, should be the primary objective of the June meeting. By the time the symposium was held, working groups had produced a draft manual for discussion.
At the symposium, which was attended by representatives from more than 50 organisations, encompassing UN agencies, governments and NGOs, the Inter-Agency Working Group on Reproductive Health in Refugee Situations (IAWG) was formed, with over 30 members from UN agencies, NGOs, research organisations and governments.
The inter-agency field manual
One of the key roles of the IAWG was to develop a draft field manual. Extensive discussion and field-testing ensued, with the final version produced in 1999. Building on the Cairo Programme of Action, the manual establishes reproductive health within essential primary health care services to be delivered during an emergency. The manual is a key technical document, intended to support the delivery of quality reproductive health services. Aimed primarily at health managers, it provides technical guidance on undertaking all aspects of reproductive health care in refugee settings.
One of the key purposes of the manual is to advocate a multi-sectoral approach to providing services, and to foster coordination between all partners. It also describes the Minimum Initial Service Package (MISP), which comprises those services that are needed in the first phase of an emergency. Separate, detailed chapters cover the technical areas of reproductive health for refugees: safe motherhood; sexual and gender-based violence; sexually transmitted diseases, including HIV/AIDS; and family planning. The manual also covers reproductive health and young people, surveillance and monitoring, information, education and communication (IEC) and legal considerations.
In 1998, UNFPA produced the Reproductive Health Kit for Emergency Situations to facilitate the implementation of the MISP described in the manual. This was based upon kits created by Marie Stopes International in 1994 for use in Bosnia. The reproductive health kit comprises 12 sub-kits for use at different health care levels, among them condoms, oral and injectable contraceptives, and drugs for the treatment of STDs. There are also sub-kits with emergency contraception for women who have been raped, and manual vacuum aspiration equipment for the treatment of post-abortion complications. The kits have been used extensively in crisis situations, including in Afghanistan, Albania, Eritrea, India, Mozambique and Sudan. Following an evaluation, they have been revised.
Reproductive health during conflict and displacement: a guide for programme managers
To complement the inter-agency field manual, WHO has designed a management guide, Reproductive Health during Conflict and Displacement: A Guide for Programme Managers. Following field-testing in a variety of refugee settings, the first edition was produced in 2000. The guide provides management tools to assess, plan, implement and evaluate reproductive health programmes. The guide positions the technical areas of reproductive health within the broader context of conflict and displacement, and includes discussion of the phases of conflict, emergency preparedness, guiding principles including a gender approach, the stabilisation phase and post-conflict rehabilitation. The guide does not aim to provide detailed clinical guidance on the technical areas of reproductive health for refugees, since this is provided in the inter-agency field manual.
The WHO guide also endorses a Core Package of reproductive health interventions; the MISP by another name. It expands on the concepts behind the MISP, and gives more detail on the implementation and actual delivery of the package of services. One clear function for the WHO guide, in contrast to the inter-agency manual, is as an orientation, awareness-raising and training tool for health care providers unfamiliar not only with emergency settings, but also with reproductive health care.
The challenge ahead
Although resources are available, including guidelines for HIV/AIDS interventions, guidelines on sexual and gender-based violence, assessment tools and training modules, as well as the two manuals described here, the challenge remains to ensure that reproductive health becomes an integral component of any humanitarian response. Currently, few agencies are consistently providing more than maternal child health services, particularly in the early stages of a crisis. There is little coordination between agencies to ensure that the complete package of reproductive health services is provided, and agencies are not held accountable for the provision of reproductive health services. A concerted drive is required to translate progress at the international level into on-the-ground services for communities affected by conflict. This will involve much more than rebuilding infrastructure and deploying medical teams. An integrated response includes training and technical assistance to build institutional capacity and leadership among NGOs, governments and other players; developing and disseminating new materials for programming and advocacy; and developing, evaluating and disseminating replicable service delivery models.
Humanitarian agencies need to ensure that comprehensive reproductive health care is integrated into their service delivery. To achieve this, targeted training is required for humanitarian workers and medical staff; reproductive health supplies need to be accessible and available from the earliest stage of the response; and funding priorities need to incorporate reproductive health services. The inter-agency field manual and WHO guide are valuable, but more needs to be done to ensure the implementation of the principles they enshrine.
Samantha Guy runs Marie Stopes Internationals Reproductive Health for Refugees Initiative.
References and further reading
Inter-Agency Field Manual on Reproductive Health in Refugee Situations (Geneva: UNHCR, 1999). Available from the Centre for Documentation for Refugees: fax: 41 22 739 73 67; email: firstname.lastname@example.org
Samantha Guy, Health Issues Affecting Displaced Populations, Refuge, vol. 18, no. 5, January 2000.
Ann Smith, HIV/AIDS and Emergencies: Analysis and Recommendations for Practice, Network Paper 38 (London: Humanitarian Practice Network, 2002).
Refugee Women and Reproductive Health Care: Reassessing Priorities (New York: Womens Commission for Refugee Women and Children, 1994).
Guidelines on the Protection of Refugee Women (Geneva: UNHCR, 1991).
Laurel Schreck (ed.), International Family Planning Perspectives (New York and Washington: Alan Guttmacher Institute, 2001).