Meeting reproductive health needs as service providers


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  • These slides of Meeting Reproductive Health Needs in Crisis is intended to help national and community reproductive health care providers respond to crisis situations and to collaborate with international relief agencies. This issue also discusses how relief agencies can address the reproductive health needs of refugees as part of emergency care. UNFPA
  • As of Jan. 2005, including people ‘of concern’ to the United Nations High Commissioner for Refugees (UNHCR), Palestinian refugees and many internally displaced persons not formally categorized as ‘of concern to the UNHCR’, over 40 million people have been displaced by conflict. In 20 months (Jan. 2004 to Sept. 2005) natural disasters have affected over 200 million people. Basic emergency services include food, water, shelter, security and primary health care with a focus on preventing infectious diseases. Increasingly, relief agencies are making reproductive health care a key emergency service. UNFPA
  • There is a lack of data from crisis situations, and this percentage (15%) is about the same as among pregnant women in general. It is assumed that maternal complications are far riskier for women in crisis situations because the majority of refugee women are in countries where pregnancy can represent a serious health threat even in normal times. The need for emergency obstetric services is acute as trauma, malnutrition, and psychological distress are widespread and health care facilities/personnel are no longer available. Among Afghan refugees barriers to health care included failure to: recognize the problem decision of family members not to seek care lack of emergency transport to a health facility not receiving good quality, timely treatment UNFPA
  • Gender-based violence can be defined as acts of violence committed against females because they are female, and against males because they are male. Includes sexual violence, domestic violence, emotional and psychological abuse, sex trafficking, forced prostitution, sexual exploitation, sexual harassment, harmful traditional practices (such as female genital mutilation and forced marriage), and discriminatory practices. Rape used as a weapon of war has been documented in Algeria, Bangladesh, Bosnia and Herzegovina, Indonesia, Liberia, Rwanda, and Uganda. Other factors that increase SGBV include overcrowding in camps and predominantly male camp leadership who do not see preventing violence as a high priority. In some instances peacemakers and humanitarian workers have been the perpetrators, exchanging food for sex by threatening to withhold food rations. UNFPA
  • A woman is more likely to disclose violence and other abuse to a female health care provider than to a male provider. Health care providers often do not ask about violence because they feel unprepared to address clients’ needs. Providers need training in counseling . Appropriate care includes a medical exam, treatment of any injuries, preventing unwanted pregnancy, treatment of STIs, including post-exposure prophylaxis against HIV/AIDS, and counseling. Providers should also refer women to a hospital for surgery, and offer transportation when needed. Documenting a woman’s injuries and symptoms helps medical staff to follow up. Documentation can help providers understand the types and extent of sexual violence and to monitor and evaluate care. Providers can reaffirm to each client that the violence against her was not her fault and no one deserves to be assaulted. Providers can work with camp management to locate water collection and latrines in well-traveled well-lit areas. Providers should try to locate health care providers within refugee community. Refugee providers may be aware of violence and can be trained to handle it. Community based strategies for social change are most feasible in the recovery phase of conflict when communities no longer face immediate disruption. UNFPA
  • The civil war in Liberia brought about widespread sexual violence, including mass rapes and the abduction of women and girls to act as sex slaves for soldiers. UNFPA
  • Women who rely on resupply methods will no longer have access when they flee their communities. Similarly, those women who use IUDs or implants no longer have access to safe removal and replacement. UNFPA
  • Worldwide, 6.6 million adolescents are displaced by armed conflict. Social support networks weaken and often breakdown entirely leaving adolescents vulnerable. UNFPA
  • Transportation and communications are often disrupted, distribution networks dissolve, and existing infrastructure is partly or completely destroyed. Local health care system may have suffered severely. Hospitals may have been looted, and medical staff may have fled or been killed. When crisis strikes, reproductive health programs cannot accommodate the influx of refugees needing services. During the Great Lakes crisis in Africa in the 1990s, 1 million Rwandans fled to surrounding Zaire, Tanzania, Burundi, and Uganda, countries with limited health services to begin with. The sheer number of people was enough to overwhelm the capacity of any agency. Most conflicts occur in developing countries where health conditions are poor, and many displaced groups already suffer from ill health, including malnutrition and STIs. Most communities are surprised by natural disaster and have little chance of responding unless emergency plans are already in place. Conflicts however, usually results from worsening political/social conditions which may provide some warning before the situation deteriorates. Conflicts are unstable, with episodes of violence and chaos preventing providers from responding effectively. In contrast, in a natural disaster, the extent of damage can be determined, and relief workers can respond more quickly. In conflict situations, opposing sides, including the government may have no regard for the health of the refugees. Health care staff can be the targets of armed groups. In contrast, in a disaster situation, there is often an outpouring of support, and the government of the affected country takes on the responsibility of mounting a response. UNFPA
  • An example of gaps in reproductive health care: Services to address sexual and gender-based violence and STIs are more limited than maternal health care or family planning services. The Colombian organization PROFAMILIA, that has provided reproductive health care to refugees, found that local organizations were already providing services to some communities. As a result, they were able to re-allocate funds to other projects assuring that more people received services. UNFPA
  • Reproductive health program directors should be aware that a number of international organizations provide reproductive health care as part of their relief efforts in crisis situations. UNHCR—the United Nations High Commissioner for Refugees leads the coordination of international response to refugee situations. RHRC Consortium—The Reproductive Health Response in Conflict Consortium, formerly known as the Reproductive Health for Refugees Consortium, promotes and provides reproductive health care in crisis situations. Consists of seven organizations. Four provide RH care directly to refugees—CARE, Marie Stopes International, the American Refugee Committee, and the International Rescue Committee. JSI Research and Training Institute and the Heilbrunn Department of Population and Family Health, Mailman School of Public Health at Columbia University, conduct research and training and provide technical assistance to local organizations. The Women’s Commission for Refugee Women and Children is an advocacy organization. IAWG focuses on strengthening RH care for refugees and internally displaced persons. Comprised of 30 organizations, including reproductive health NGOs, UN agencies, and academic institutions. As of 2003, UNICEF had worked in 60 conflict-affected countries. UNICEF provides clean delivery kits for use in conflict situations. UNFPA is the largest supplier of emergency reproductive health supplies and equipments. Supports projects in over 50 countries. UNRWA exclusively provides emergency aid, relief services, education, and health services to Palestinian refugees. This includes family planning and maternal and child health care. IMC helps local communities by providing RH care including MCH and HIV/AIDS/STI prevention, and by providing training to increase awareness of sexual and gender-based violence. IMC health professionals recruit and train local providers to ensure health programs are sustainable. RI is an advocacy organizations. Among its services, RI addresses sexual violence, family planning and emergency obstetric care. Within the US government, the State Department Bureau of Population, Refugees and Migration and the USAID Office of Foreign Disaster Assistance share responsibility for refugees assistance programs. They provide substantial assistance in humanitarian crisis situations. The European Commission Humanitarian Aid Office funds refugee projects worldwide, including emergency reproductive health care. The ECHO program, Aid for Uprooted People, focuses on creating conditions that foster long-term development. In Asia and Latin America it provides funds to refugee camps, for repatriation, and to assist with reintegration into communities. UNFPA
  • More and more donors are allocating money for specific programs and telling relief agencies how they want their money spent. Overall levels of funding for humanitarian assistance increased from $2.1 billion in 1990 to $5.9 billion in 2000. Donor funding tends to focus on a few large-scale emergencies. Political priorities within donor countries determine the amount of funding that goes to specific emergencies. Also, emergencies that are covered extensively by the media tend to generate more interest and money. Sometimes donors tend to focus more on one aspect of reproductive health at the expense of other aspects. For example, HIV/AIDS funding in conflict situations has increased. Donors see AIDS prevention as separate from other reproductive health rather than an integral part of it. UNFPA
  • How can family planning providers help in crisis situations? Health care providers understand people’s needs and have experience meeting them, but few have worked in humanitarian relief. By learning more and being prepared family planning providers and managers—whether at the community level or internationally—could help in several ways. UNFPA
  • International agencies, governments, community programs, and local health care providers can work together to build their capacity for crisis response. H.E.L.P. is a three week module focused on reproductive health that gives providers the tools to make decisions in large-scale emergency situations. Although intended primarily for health professionals, anyone in a decision-making position can participate. IRC course addresses key public health issues, including reproductive health coordinators, program managers, and district medical officers from international and national health organizations. UNFPA
  • Adequate storage facilities are not available and program managers must find ways to minimize damage to supplies. Roads are often impassable, fuel supplies are inadequate, utilities do not work, and security is compromised. In planning logistics for emergencies, reproductive health care providers should understand that demand for contraceptives continues. UNFPA
  • The news media can provide survivors with information about the security situation, where to find shelter, food and water, and health services including reproductive health care. Public awareness usually determines the level of attention that an emergency receives. UNFPA
  • Humanitarian providers and government officials in charge should anticipate the needs of the news media and provide them with the facts needed. Organizations should designate a person with direct access to decision makers and train this person for working with the news media. UNFPA
  • Reproductive health field guides and other materials that humanitarian agencies use can also help local providers. The field manual is the most comprehensive and widely used guide for refugee reproductive health programs. It is a key tool for planning, implementation, monitoring, and evaluation. It can help programs introduce and strengthen reproductive health activities that respond to refugees’ needs. UNCHR published a 1999 revision of the manual after two years of field use and testing by staff in 50 relief agencies. The MISP is a series of activities and supplies designed to avoid maternal and neonatal deaths and illness, reduce HIV transmission, prevent and respond to sexual and gender-based violence, and plan for integrating reproductive health care with primary health care. UNFPA
  • Local providers need not wait for relief agencies to ask for community assistance. For example, in Sri Lanka, Marie Stopes International helped a local agency mobilize teams of community reproductive health workers to help victims of the 2004 tsunami. UNFPA
  • The ability to do so would depend on the level of international support their receive. Many programs barely have enough resources to provide basic care for their usual clientele on a day-to-day basis. UNFPA
  • Doris Bartel, a senior reproductive health expert with the RHRC Consortium suggests what a reproductive health provider can do immediately to begin to help. You can ask a UNFPA, UNICEF or international NGO representative responding to the crisis to order supplies according to how many people you think you can serve. UNFPA
  • Meeting reproductive health needs as service providers

    1. 1. Meeting ReproductiveHealth Needs in Crisis Coping with Crises: How Providers CanMeet Reproductive Health Needs in Crisis Situations
    2. 2. Millions Need Care in Crises• Every year natural disasters and conflicts kill and displace millions of people.• Conventionally, humanitarian and relief workers have focused on providing basic emergency services.• Reproductive health care is a serious public health issue in crises that deserves more attention. UNFPA
    3. 3. Overview• Crises Pose Major Challenges for Reproductive Health Care – Range of reproductive health care needed – Providers face unique challenges – International Response• Reproductive Health Care Providers Can Help – Joining the Inter-Agency Working Group – Disaster preparedness – Following guides to crisis care – Building links – Focusing on refugees not in camps – What to do first in a crisis – After the crisis UNFPA
    4. 4. Crises Pose Major Challenges forReproductive Health Care UNFPA
    5. 5. Range of Reproductive Health Care Needed• Safe motherhood• Protection and response to sexual and gender-based violence• Prevention and treatment of STIs including HIV/AIDS• Family planning• Adolescent reproductive health UNFPA
    6. 6. Safe Motherhood• In crisis situations 15% of pregnant women suffer life-threatening complications of pregnancy and delivery.• Maternal complications are riskier for women in crisis situations.• Better care could prevent most maternal deaths. – Study of Afghan refugees in Pakistan found that, compared with women who died of other causes, those who died of maternal causes faced greater barriers to health care. UNFPA
    7. 7. Sexual and Gender-based Violence• Armed conflict leads to widespread sexual and gender-based violence (SGBV). – Occurs during all phases of conflicts• Most often women and girls, but men and boys also affected.• SGBV increases with loss of security, trauma, • . ethnic tensions and breakdown of society.• Domestic violence also increases. – East Timor: Half of women reported abuse by intimate partners, both during the crisis and afterwards. UNFPA
    8. 8. Health Care Providers Can Help Reduce Violence• Caring for Survivors: • Preventing Violence in – Ask a client about abuse. Camps: – Providers should be alert – Work with camp to physical injuries, management. health conditions, and – Work with refugee health clients’ behavior that care providers. indicates trauma. – Advocate leadership by – Provide appropriate care. women. – Document the woman’s – Work with security condition. forces. – Support women’s self- – Involve the community. esteem. UNFPA
    9. 9. HIV/AIDS and Other STIs• Coupled with crisis situations, HIV and other STIs can spread rapidly.• Poverty, powerlessness, food insecurity, and displacement make refugees more vulnerable. – In Liberia, HIV prevalence was estimate at 8%. STI screenings after the war showed 93% of male combatants and 83% of female combatants had at least one STI. UNFPA
    10. 10. Family Planning• Family planning is in as much demand during a crisis as it was beforehand.• Refugees have far less access because services and supplies are disrupted.• Results are unintended pregnancies and rising abortion rates.• Women relying on contraceptive methods may have to discontinue abruptly. UNFPA
    11. 11. Adolescent Reproductive Health• Adolescents, especially girls are at risk of forced sex and sexual coercion in exchange for food, shelter and protection.• Unsafe sex and risk-taking among youth increase in crisis. – In a refugee camp in Kenya, despite availability of free condoms 70% of young men and women had unplanned sex without condoms. UNFPA
    12. 12. Health Care Providers Face Unique Challenges• Crises disrupt services• Crises overwhelm health systems• Crises come on top of existing problems• Conflicts and natural disasters create different problems for providers UNFPA
    13. 13. International Response Improving• Reproductive health care for refugees has improved, but gaps remain.• In the last 20 years the international community has paid increasing attention to the reproductive health needs of refugees.• Relief agencies and local agencies working together can avoid duplication of services and wasting resources. UNFPA
    14. 14. International Relief Agencies Provide Reproductive Health Care• UNHCR• RHRC Consortium• The Inter-Agency Working Group on Reproductive Health in Refugee Situations (IAWG)• UNICEF, UNFPA, and UNRWA• The International Medical Corps (IMC)• Refugees International (RI)• US Government Agencies• ECHO UNFPA
    15. 15. Not Enough Funding• Relief agencies often cannot provide complete reproductive health care for refugees due to lack of funds.• United States and European Union, provide most of the funding.• Since 2000, funding for reproductive health care has declined as donor priorities have shifted. UNFPA
    16. 16. Reproductive HealthCare Providers Can Help
    17. 17. Join the Inter-Agency Working Group• Inter-Agency Working Group on Reproductive Health in Refugee Situations (IAWG) seeks to improve interagency collaboration and reproductive care for those in crisis situations.• Providers can join IAWG electronic mailing list to receive updates on reproductive health care in crisis.• Providers can join or start a national, district, or local interagency working group that can serve as a focal point to collaborate with relief agencies. – For further information, contact Henia Dakkak at UNFPA UNFPA
    18. 18. Develop Emergency Preparedness Plans• If local communities and NGOs are trained and prepared for disasters, a quicker response can be mounted.• International organizations offer disaster preparedness training courses. – Health Emergencies in Large Populations (H.E.L.P.) course offered by International Committee of the Red Cross (ICRC). – Public Health in Complex Emergencies course offered by International Rescue Committee (IRC). – In addition, numerous training tools specifically address reproductive health in conflict situations. UNFPA
    19. 19. Pay Attention to Logistics• Crisis situations present special logistical challenges.• Any reproductive health program can design and use a basic logistics management information system. – Contraceptive Logistics Guidelines for Refugee Settings (DELIVER) outlines basic principles of logistics management: -calculating contraceptive needs -calculating average monthly consumption -how to store contraceptives. UNFPA
    20. 20. Create a Skills Roster• Providers need to quickly identify people with essential skills.• Many refugees have training in health care, but their skills can be used in a relief effort only if they are known.• Without a skills roster, expertise can go unused. – In Tanzanian camps after the Rwandan genocide, some providers knew how to insert and remove implants, but relief workers did not know about provider skills. Women who needed these services did not have access. UNFPA
    21. 21. Establish a Relationship with the News Media• Governments and humanitarian agencies should have a plan of working with news media.• Media can provide survivors with critical information.• News media are often the first to define an event as an emergency and raise public awareness and concern. UNFPA
    22. 22. Working with the News Media• Find ways to help the media report the news by providing them with accurate facts.• Respect media deadlines.• Always be truthful and factual.• Use language that is clear, concise, and easy to understand. UNFPA
    23. 23. Follow Guides to Crisis Care• The Inter-Agency Field Manual is a key tool.• Use the Minimum Initial Service Package (MISP). – Applies to both conflict and natural disasters. – A series of activities and supplies designed to deal with reproductive health issues in crisis situations. – Intended for the acute phase of a crisis. – Can be implemented immediately without a needs assessment. UNFPA
    24. 24. Build Links• Coordination between relief organizations and local health systems can combine the experience/expertise of relief workers and local health care providers.• Local providers can take the first step and offer their services.• Local agencies may receive funding, supplies, and equipment from UN and other international agencies. UNFPA
    25. 25. Focus on Refugees Not in Camps• International relief organizations and NGOs can work with local reproductive health care providers to offer care for refugees who are not in camps.• Refugees living in host communities often receive less health care.• Health care providers who are able to continue serving their regular clients may be able to incorporate refugees into their services. UNFPA
    26. 26. What To Do First in a Crisis• Approach someone working • If there are many displaced for a UN organization and ask people, talk to relief workers which organizations and/or organizing shelter, water, individuals are coordinating latrines and food. RH care or the MISP.• Offer your services and • If you know how to set up provide your qualifications. water pumps and latrines let• If your clinic/hospital has the them know. skills or equipment to provide • Work with those distributing any component of the MISP, food rations to make sure start immediately. women are equally• Ask for supplies from relief represented. organizations. Also ask that • Make sure sanitary supplies they include your clinic in distribution of supplies. as well as clean delivery kits• Go to reproductive health are distributed with food care coordination meetings rations. UNFPA
    27. 27. After the Crisis: From Disaster to Development• Even after conflicts or natural disasters end, suffering often continues.• People need continued support to help rebuild their lives.• During the transition to post-emergency relief and recovery, humanitarian providers can cooperate with other local providers and coordinate activities that focus on sustainability. UNFPA