This is the abstract presentation of Sahlil Ahmed, which was presented as part of the 9th session of #APCRSHR10 Virtual, on the theme of "Humanitarian response and sexual and reproductive health and rights (SRHR) in Asia and the Pacific". C H A I R Chonghee Hwang Senior Manager, Family Planning 2020 (FP2020) P L E N A R Y S P E A K E R Tomoko Kurokawa Humanitarian Advisor, UNFPA Asia Pacific "Building Resilience across the Humanitarian Development Peacebuilding Nexus" A B S T R A C T P R E S E N T E R S * Sahlil Ahmed | Challenges Health Workers Face While Providing Sexual and Reproductive Health Services to Rohingya Refugees in Refugee Camps in Cox’s Bazar, Bangladesh: A Qualitative Study * Sayantan Chowdhury | Genesis of maternal mortality surveillance and response in the Rohingya refugee crisis * Sigma Ainul | Contraceptive non-use among the Rohingya and changing dynamics in post-displacement to Bangladesh * Manju Karmacharya | Transitioning from Minimum Initial Service Package to Comprehensive SRHR services responding Rohingya crisis in protracted Emergency in Cox’s Bazar, Bangladesh For more information on this session go to www.bit.ly/apcrshr10virtual9 #SRHR #sexualhealth #reproductiverights #familyplanning #womenshealth #genderequality #SDGs #BodilyAutonomy #humanitariancrisis #humanitariandisaster #pandemic

1. Challenges Health Workers
Face While Providing Sexual
and Reproductive Health
Services to Rohingya
Refugees in Refugee Camps
in Cox’s Bazar, Bangladesh: A
Qualitative Study
Sahlil Ahmed (MPH,MBBS)

2. Outline
• Background
• Conceptual Framework
• Methodology
• Findings
• Conclusion and
Recommendations

3. Background
• Rohingya crisis is one of the largest crisis globally;
about one million living in camps in Cox’s Bazar
(UNICEF,2018)
• With many health challenges there is a huge unmet
need of SRH services (ISCG, 2018)
• Providing safe, acceptable and effective sexual and
reproductive health services is challenging (Nair et al.,
2015)
• Health workers remain unaware of the demands of
humanitarian crises (Bjerne, Lindmark, Diskett, & Garrett, 2004)
• Performance of health workers in humanitarian crises depends on a variety of factors (Salam, Das,
Lassi, & Bhutta, 2016)

4. Background
• Few research done for understanding the
health workers’ perspectives on providing
healthcare to refugees (Lawton et al., 2017)
• Few studies explored the health workers’
experiences in humanitarian settings
focusing on their challenges (Bjerne, Lindmark,
Diskett, & Garrett, 2004)
• Scarcity of research led to a lack of evidence
for improvement of training and supports in
crises settings

5. Conceptual Framework
Health workers’ capacity related
challenges
• Lack of knowledge of critical SRH care
• Inadequate skill and technical capacity
• Lack of training & experiences
• Knowledge gap on refugees’ health needs
• Lack of proficiency for counselling &
consultation
• Language & cultural barriers
Logistics & system related challenges
• Increased workload
• Stock outs of minimal essential elements
• Working in under-resourced facilities
• Shortage of funding
• Unavailability of essential elements
• Uncertain nature of job
• Insecurity
Challenges for
health workers
Impact on health workers
Negative psychological symptoms
of-
• Anxiety & distress
• Feeling of helplessness,
isolation & hopelessness
• Frustration
Overall quality of the
delivered services is affected

6. Methodology
 Study Design: Qualitative Study
 Study Sites:
• 10 primary healthcare centers and 5 fixed health posts; 1 secondary hospital and
Ukhiya Health Complex
 Data collection method:
 Sampling technique:
• Purposive sampling ( camp and health facilities) & Convenient sampling (respondents)
• 3 Medical doctors, 5 midwives, 2 paramedics10 IDIs
• Each consisting of 6 CHWs2 FGDs
• Persons involved in designing interventions, providing technical
assistance and training or managing health centers providing SRH
5 KIIs

7. Findings

8. Socio-demographic characteristics of the respondents
• Gender: 3 Male, 24 female
• Range of age group: 18-31 years
• Range of total working experience: 2
months - 6 years
• Range of total working experience in
Rohingya camps: 2 months – 1.3 years

9. Challenges of health workers
Challenges related to
service delivery strategy
implementation
Challenges
Context specific
challenges
Service delivery
related challenges

10. Context specific challenges
“For most of the cases I didn’t even know
the problems that may arise.” (Paramedic,
PHC, 23 years)• Lack of contextual orientation
• Language barrier
• Counselling to patients
• Acceptance to community
• Security
• Community’s understanding of
illness
• Condition of the roads, seasonal
variation and location of the
health facilities
“As a doctor you might feel that medicine is
not necessary, but for a patient that is very
important. So it’s tough to meet their
expectations. ” (Clinical supervisor, Female, 31
years)

11. Service delivery related challenges
• Increased workload
• Supply of essential drugs and
equipment
• Diagnosing a disease
• Referral
• Inadequate knowledge and skill
on SRH
• Unspecified job description
“We didn’t give enough training to the
community health workers. We have to
make them understand about the
importance of SRHR.” (SRHR working group
member, Female)
“To do proper counselling is tough as we
get around 150 patients per day. If we try
do give them proper counselling it will be
impossible for us.” (Doctor, female, 26
years)

12. Challenges related to service delivery strategy
implementation
“If we want to convince the higher authority
about SRH, it won’t help if 1-2 people say,
when a topic is raised from coordinator or
organization level, it will be prioritized.”
(Senior midwife supervisor, Female, 29 years)
"Almost all the people know the importance
of PHC, but when it comes to RH, people only
think about pregnancy and delivery care.
”(SRH project manager, Male, 45 years)
• Staff turnover
• Maintaining privacy in
the health facilities
• Prioritizing SRH

13. Gender Dimension of the challenges
Challenges
Female health
workers
Acceptance to
community
Location of facilities
& road condition
Security
Feels insecure while working in
community & facilities inside
the camps & during night duty
More challenging to reach
community & facilities in
remote location & during rainy
season specially for CHWs
More acceptance to female
patients
Feels insecure while working in
the facilities inside camps
Less challenging as don’t need
to move in the community
Less acceptance to female
patients
Male health workers

14. Intensity of challenges perceived by health workers
List of challenges Doctors Midwives Paramedics CHWs
Lack of contextual orientation +++ +++ +++ +++
Language barrier +++ +++ +++ +++
Counselling +++ +++ +++ ++
Community’s understanding
of illness
+++ ++ + ____
Physical barriers + + + +++
Increased workload +++ + + +++
Supply of essential drugs and
equipment
+++ ++ + +
Diagnosing a disease +++ +++ _____ ____
Referral + ++ _____ ____
Inadequate knowledge and
skill on SRH
____ ____ ++ +++
Unspecified job description ____ ____ + +++
Here, +++ = perceived as Most challenging, ++ = perceived as More challenging, + = perceived as challenging & -
____ implies that it was not perceived as a challenge by that specific type of health workers

15. Impacts of challenges faced by health workers
Less consultation time due to
increased workload
Challenges
Unavailability of essential drugs
Following organizational rules &
dealing with personal values
Convincing patients of the need of
medicine against meeting their
perceived needs
Lack of knowledge and technical
skill on SRH
Impacts on health workers:
• Stress, depression, anxiety &
distress
• Feeling of insecurity,
hopelessness & helplessness
Impacts on service quality:
• Decreased quality
• Patient’s dissatisfaction
• Decreased service utilization
by the patients
Impacts

16. Conclusion and recommendations
• There is a lack and need for SRH
information and technical
knowledge
• Adequate training, contextual
orientation, psychological and
organizational support is needed
• CHWs need to be more focused
while arranging training sessions
• Need based capacity building is
required

17. Acknowledgements
• Respondents
• Supervisor: A.S.G Faruque (Consultant, icddr,b)
• Co Supervisor: Bachera Aktar (Assistant Director, BRAC James P Grant School of
Public Health, BRAC University)
• Mentors: Atiya Rahman, Nadia Farnaz , Abdul Awal
• Team Members: Shagoofa Rakhshanda, Christine Nderitu, Basanta Thapa, Samuel
Saidu
• Wafa Alam
• BRAC James P. Grant School of Public Heath, BRAC University

18. Thank you