Reproductive Health Care Providers Can Help

How can family planning providers do more to help in crisis situations? Health care providers understand people’s needs and have experience meeting them, but few have worked in humanitarian relief (32). By learning more and being prepared, family planning providers and managers— whether at the community level or internationally—could help in several ways:

• Join the Inter-Agency Working Group (IAWG);
• Develop emergency preparedness plans for their facilities, organizations, and communities, including establishing a relationship with the news media;
• Follow guides to crisis care, particularly the Minimum Initial Service Package (MISP);
• Build links with relief agencies;
• Focus on refugees not living in camps; and
• Assist the transition from relief to reconstruction.

Join the Inter-Agency Working Group

Any reproductive health organization or humanitarian relief agency can join the Inter-Agency Working Group on Reproductive Health in Refugee Situations. Established in 1995, the working group seeks to improve interagency collaboration and improve reproductive health care for people in crisis situations, among other objectives (45, 93).

Reproductive health care providers can join the IAWG electronic mailing list to receive updates on reproductive health care in crisis situations. Additionally, providers can join or start a national, district, or local interagency reproductive health working group. These groups could serve as focal points and collaborate with relief agencies that work with refugees. (For further information contact Nadine Cornier at UNHCR, (CORNIER@unhcr.ch)

Disaster Preparedness

A growing focus on community-based preparedness is replacing the conventional approach to disaster preparedness, which has emphasized centralized emergency response. If local communities and NGOs are trained and prepared, a quicker response can be mounted and more lives can be saved (40). International agencies, governments, community programs, and local health care providers can work together to build their capacity for crisis response. They can anticipate the demand for care in a crisis situation, develop effective logistics systems, create rosters of people with the skills urgently needed during crises, and establish relationships with the news media.

Emergency preparedness plans should consider staffing, logistics, supplies, and infrastructure. Above, a local emergency brigade in El Salvador discusses disaster prevention and risk management, post-hurricane Mitch. (Photo Credit: © 2001 Jim Stipe/Lutheran World Relief, Courtesy of Photoshare.)

Disaster preparedness training. Training can help international and local health care providers and government officials respond quickly and effectively when a disaster or crisis occurs.Many countries offer disaster preparedness training through the International Committee of the Red Cross (ICRC). An example is the “Health Emergencies in Large Populations (H.E.L.P.)” course, 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 (39).

Also, the International Rescue Committee (IRC) offers a two-week training program,“Public Health in Complex Emergencies.”This course addresses key public health issues, including reproductive health care, that providers face in emergencies.The course is intended for medical coordinators, public health coordinators, program managers, and district medical officers from international and national health organizations (44).

In addition, numerous training tools specifically address reproductive health in conflict situations. For example, CARE, on behalf of the RHRC Consortium, has developed a series of 10 training modules,“Moving from Emergency Response to Comprehensive Reproductive Health Programs.” (For more information on training, see Table 4 and Web Table 1)

Logistics. Uninterrupted flow of supplies is a basic requirement for good-quality reproductive health care at any time (2, 22). Crisis situations, however, present special logistical challenges. In most crisis situations adequate storage facilities are not available, and program managers must find ways to minimize damage to supplies (19). Also, roads are often impassable, fuel supplies are not adequate, utilities no longer work, and security is compromised (27, 75).

Crises often undermine existing contraceptive logistics systems that were weak to begin with. Nonetheless, any reproductive health program can design and use a basic logistics management system in crisis situations to help decide what supplies to stock, how much to stock, and when to reorder. Principles of contraceptive logistics are generally the same in a crisis situation as at other times (22). A logistics management information system (LMIS) identifies, at a minimum, stock on hand, stock on order, and average monthly consumption (19). Storage and transportation of contraceptives are necessary infrastructure.

The DELIVER project of John Snow, Inc. (JSI) has developed a manual, Contraceptive Logistics Guidelines for Refugee Settings, which outlines basic principles of logistics management.The manual explains how to calculate contraceptive needs, how to develop a basic LMIS, and how to store contraceptives, among other information.

In planning logistics for emergencies, reproductive health care providers should understand that demand for contraceptives continues. In fact, demand often becomes more urgent.Many people lose access to sources of supplies and services that they had relied on, including contraceptives and condoms to prevent STI transmission, as well as supplies and equipment to treat complications of labor and delivery and to treat the consequences of sexual and gender-based violence (37). If possible, when contraceptive supplies are disrupted, emergency contraception (EC) should be made available to any woman who has had unprotected intercourse. Promoting awareness of EC is important because the drug must be taken as soon as possible after unprotected sex, for maximum effectiveness.

Some government officials have said that in crisis situations people do not need family planning services because they will not be having sex or, alternatively, because they will want more children to rebuild their families in the face of so much loss of life (37). While some refugees may feel this way, many others want to avoid pregnancy in a crisis because they have few resources and face the trauma and uncertainties of displacement (35).

Family planning statistics help to demonstrate the extent of the need. In Indonesia after the December 2004 tsunami, for example, the immediate need for family planning was estimated at approximately 80,000 contraceptive units (including condoms and other methods), while the available stock was about 16,000 units (9, 67, 83).

Create a skills roster. To respond effectively in a crisis situation, providers must be able to quickly identify people with essential skills (33). It can help to collect information in advance on the availability of health care providers and others with family planning and reproductive health skills. Gathering information from refugees in camps can also be useful.Many refugees have training in health care and some may be health professionals, but their skills can be incorporated into the overall effort only if they are known to relief organizers (18).

Without a skills roster, expertise can go unused. For example, in Tanzanian camps after the Rwandan genocide, some providers knew how to insert and remove implants. Relief workers did not know about these providers’ skills, however, so women who needed such services did not have access to them (33).

The Inter-Agency Field Manual helps programs introduce and strengthen reproductive health activities that respond to refugees’ needs and reflect their values.

Establish a relationship with the news media. As part of disaster preparedness, governments and humanitarian agencies should have a plan of working with the news media in crisis situations (77). In times of conflict and natural disaster, radio and other media can provide survivors with information about the security situation and about where to find shelter, food and water, and health services including reproductive health care (21).The broadcast media may well be the only working means of communicating with the public.

News reporters often are the main source of firsthand information about the extent of crises and the problems that survivors and relief efforts face.The news media are often the first to define an event as an emergency and to raise public awareness and concern. In turn, the extent of public awareness usually determines the level of attention that an emergency situation receives (10).

To work effectively with the news media, humanitarian providers and government officials in charge of crisis response should anticipate the needs of the news media and be able to provide them with facts needed for accurate reporting (68). Organizations should designate a person with direct access to decision makers and train this person for working with the news media. Keys to working well with the media include finding ways to help the media report the news, respecting media deadlines, always being truthful and factual, and using language that is clear, concise, and easy to understand (13, 78).

Table 4. Key Resources for Reproductive Health Care in Crisis Situations
Educational Resources
Organization: International Committee of the Red Cross Title: Health Emergencies in Large Populations (H.E.L.P.) Course Description: Three-week course with two training modules. Gives providers a better understanding of disaster preparedness. Covers reproductive health needs of displaced populations.				Availability: For more information see the web site or write to: International Committee for the Red Cross, HELP Courses 19, Avenue de la Paix CH-1202 Geneva, Switzerland
Organization: International Rescue Committee Title: Public Health in Complex Emergencies (PHCE) Training Program Description: Two-week course designed to give providers a better understanding of how to respond to the health needs of refugees and internally displaced persons.	Availability: For more information see: E-mail: shortcourse@theirc.org • Web site: http://www.theirc.org/phce Or write to the attention of Lorna Stevens at: International Rescue Committee (IRC) 122 E. 42nd Street New York, NY 10168, USA Tel: +1 212 551 3005 • Fax: +1 212 551 3185
Guides and Guidelines
Organization: CARE on behalf of Reproductive Health Response in Conflict Consortium (RHRC Consortium) Description: A practical guide for field staff working with displaced populations. Ten modules can be used separately or together to create a training program. Includes training materials, presentation slides, participatory exercises, and resource materials. (Draft for field testing)	Title: Moving from Emergency Response to Comprehensive Reproductive Health Programs Availability: To order printed copies or CD-ROM, write to: CARE 1625 K Street, NW, Suite 500 Washington, DC 20006, USA
Organization: John Snow, Inc./Family Planning Logistics Management Title: Contraceptive Logistics Guidelines for Refugee Settings Description: Providers can use this manual to design and implement simple contraceptive logistics systems in refugee camps where family planning programs are already in place.	Availability: Download Guidelines To order printed copies, write to: John Snow, Inc. DELIVER Project/ 1616 N. Fort Myer Drive, 11th Floor Arlington, VA 22209, USA Tel: +1 703 528 7474 • Fax: +1 703 528 7480
Organization: Inter-Agency Standing Committee (IASC) Title: Guidelines for HIV/AIDS Interventions in Emergency Situations Description: Information on developing responses to HIV/AIDS during crises. A matrix that can be photocopied helps obtain information in chart form.	Availability: Download PDF To order printed copies, e-mail martinez@unfpa.org or write to: Media Services Branch, IERD UNFPA 220 East 42nd St. New York, NY 10017, USA
Tools and Kits
Organization: United Nations High Commissioner for Refugees (UNHCR) Title: Inter-Agency Field Manual Description: A tool for planning, implementing, monitoring, and evaluating care in conflict situations. Help field staff introduce and strengthen activities that are based on refugees' and internally displaced people's needs, interests and values.	Availability: Download Manual For printed copies in English, contact: Women, Ink. 777 United Nations Plaza New York, NY 10017, USA Tel: +1 212 687 8633 ext 212 • Fax: +1 212 661 2704 E-mail: wink@womenink.org • Web site: http://www.womenink.org/
Organization: Women’s Commission for Refugee Women and Children Title: Minimum Initial Services Package (MISP) Fact Sheet and Insert (Monitoring and Evaluation Checklist) Description: Description of the MISP and the contents of its reproductive health kits. Provides information about ordering the UNFPA reproductive health kits and the New Emergency Health (Kit-98).	Availability: Download Fact Sheet or Insert For information on the New Emergency Health Kit-98, contact: IDA Foundation P.O. Box 37098 1030 AB Amsterdam, The Netherlands Tel: +31 20 403 3051 • Fax: +31 20 403 1854 E-mail: info@ida.nl
Organization: United Nations Population Fund (UNFPA) Title: UNFPA Reproductive Health Kits for Emergency Situations Description: Materials for use in the acute phase of an emergency. Consists of 12 subkits that include condoms, delivery supplies, post-rape supplies, contraceptives, surgical delivery equipment, and blood transfusion supplies. Each subkit can be ordered separately. (Note: this kit can be used to implement the Minimum Initial Service Package.)	Availability: Order kits from UNFPA Procurement Unit 220 East 42nd St. New York, NY 10017, USA Tel: +1 212 297 5384 Fax: +1 212 297 4916 E-mail: myint@unfpa.org or dsmith@unfpa.org Or from: UNFPA Emergency Relief Office 9 Chemin des Anemones 1219 Geneva, Switzerland Fax: +41 22 979 9049 E-mail: unfpaero@undp.org Web site : www.unfpa.org
Organization: United Nations Children Fund (UNICEF) Title: Clean Delivery Kits Description: These clean delivery kits can be used by traditional birth attendants or by pregnant women themselves. Each kit contains a plastic sheet, two pieces of string, one clean razor blade, and one bar of soap.	Availability: Kits can be made locally or ordered from: UNFPA Procurement Unit 220 East 42nd St. New York, NY 10017, USA Tel: +1 212 297 5384 • Fax: +1 212 297 4916 E-mail: saunders@unfpa.org or contact UNICEF country office
Additional information on resources can be found in Web Table 1.

Follow Guides to Crisis Care

Reproductive health field guides and other materials that humanitarian agencies use also can help local providers.The Inter-Agency Field Manual—the most comprehensive and widely used guide for refugee reproductive health programs—is a key tool for planning, implementation, monitoring, and evaluation (93). It can help programs introduce and strengthen reproductive health activities that respond to refugees’ needs and reflect their values (24).

UNHCR published a 1999 revision of the manual after two years of field use and testing by staff in 50 relief agencies.The revised manual can be downloaded from the Internet or ordered by mail. (For more information on availability of the Inter-Agency Field Manual, see Table 4)

A key tool—the Minimum Initial Service Package. A key component of the Inter-Agency Field Manual is the Minimum Initial Service Package. The package (often referred to as 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 (93, 117).

The Minimum Initial Service Package applies both in conflict situations and in natural disasters. It is intended for the acute phase of a crisis and can be implemented immediately, without a needs assessment (93). Its developers, the Inter-Agency Working Group, created the MISP to:

• Give health care providers the tools that they need to deal with critical steps in a natural disaster or conflict where many people are displaced;
• Minimize mistakes that health care workers might make because they are unfamiliar with crisis situations; and, as a result,
• Save lives.

Although relief agencies have become increasingly aware of this innovation, most have yet to implement it completely. For example, in Sudanese refugee camps in Chad, few relief workers knew about the MISP or about the importance of emergency response to reproductive health needs. Relief agencies made efforts to prevent sexual violence by setting up latrines and water supply points in safe locations and in some camps establish refugee committees with equal male and female representation. They did not, however, take other steps, also called for in the MISP, that would have helped avoid sexual violence and would have addressed other aspects of reproductive health (116).

Similarly, after the tsunami in Indonesia, a study found that about half of humanitarian providers interviewed were aware of the MISP, but few could accurately describe its objectives and priorities (119). In Banda Aceh UNFPA designated a “reproductive health focal point,” recommended as the first step in the MISP—that is, an individual or organization that coordinates and implements the service package—and set up working group meetings among local and international organizations. These meetings demonstrated the effectiveness of a reproductive health focal point to coordinate emergency reproductive health care. Nonetheless, other steps called for in the MISP—for example, managing consequences of sexual violence, reducing HIV transmission by practicing universal precautions, and taking adequate measures to decrease neonatal and maternal mortality—were not put in place (119).

The Inter-Agency Working Group on Reproductive Health in Refugee Situations recommends that all international organizations integrate the MISP into their emergency preparedness training and response plans and increase awareness of reproductive health in these situations (100). Similarly, governments and particularly ministries of health can prepare for emergency situations by familiarizing themselves with its goals, objectives, and components (116, 119).

Build Links

Better coordination between relief organizations and local health systems can lead to more integrated and efficient reproductive health care in crisis situations, both for community members and for refugees. Cooperation can combine the differing but complementary experience and expertise of relief workers and local health care providers.

Reproductive health care providers need not wait for international humanitarian agencies to ask for community assistance in a crisis situation. Instead, they can take the first step by offering their services (28, 47, 79).They could go to reproductive health care coordination meetings to make their observations about the crisis and explain how they are responding (5) (see 'What To Do First in a Crisis').

Local agencies responding in a crisis may receive funding, supplies, and equipment from the UN and other international agencies (46). In Sri Lanka, for instance, Marie Stopes International, a member of the RHRC Consortium, helped a local agency mobilize teams of community reproductive health workers to help victims of the 2004 tsunami (29).

Cooperation among agencies has become more important in recent years as the nature of crisis situations has changed. Humanitarian crises have become more complicated in the last 15 years, and the number of people displaced within their own countries has increased drastically. As a result, providing adequate health services in these situations has become more difficult (11, 64). As the number of NGOs and other groups involved in humanitarian relief has increased to address this need, so have problems of organization, coordination, and accountability (66).

The services that refugees receive from relief organizations largely depend on which organizations provide care. Criteria do not exist specifying which NGOs should offer which services, which camps they should serve, or how these matters should be decided (72).The lack of criteria means that the kind and quality of reproductive health care that people receive in crisis situations can vary substantially, depending on which agency responds.

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 but instead are living in the host communities. Refugees living in communities often receive less health care than other community residents. For example, Burmese refugee women in Thailand living outside the refugee camps had less access to modern contraception and other reproductive health care than the general population, and their rates of unwanted pregnancy and maternal health problems were higher (8).

When refugees are dispersed among the general population, health care providers who are able to continue serving their regular clients—that is, if their work has not been disrupted—may be able to incorporate the refugees into their services, offering them the same quality of care (56).Their ability to do so, however,would often depend on the level of international support.Many programs have barely enough resources to provide basic care for their usual clientele on a day-to-day basis. Nevertheless, with adequate funding and supplies, local providers may be better able than international agencies to provide good care, because they understand the culture and people’s needs, particularly if they are dealing with internally displaced refugees from within their own country (28).

After the Crisis: From Disaster to Development

Even after conflicts or natural disasters end, suffering often continues.Many refugees return home to find their communities in ruins and health care and other services destroyed. People usually need continued support to help them recover and rebuild their lives (70).

Health care programs can help the survivors of crises regain responsibility for their own health and well-being (6, 115). Most crises eventually move from an acute stage through a stabilization phase to a post-emergency relief and recovery phase. During this transition humanitarian providers can cooperate with other local health care providers and coordinate activities that focus on sustainability to help communities rebuild as quickly as possible (52).

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