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RHO archives : Topics : Refugee Reproductive Health

Overview and Lessons Learned

Introduction

As of the end of 2003, 35.5 million people around the world had fled their homes to escape persecution, war, and violence. Some crossed national boundaries to become refugees under international law, but most are internally displaced within their own countries. Still others are trapped in their homes as conflicts unfold around them. Complex emergencies pose a great risk to the health of populations who are suddenly exposed to new risks and lose access to basic health services. The health consequences of war are especially profound for vulnerable groups such as unaccompanied minors, pregnant women, and the elderly.

During displacement, war-affected populations, both women and men, endure physical hardship and fatigue. Inadequate food and unsafe drinking water undermine their nutritional status. In crowded camps they face increased exposure to infection, including sexually transmitted infections (STIs). They must cope with the psychological trauma of losing family members along with their homes, possessions, and jobs. Women and girls, however, face additional stresses. They are frequent victims of sexual and gender-based violence during and after their flight, and they may be pressured to exchange sexual favors for food and shelter. Many carry the emotional and financial burdens of becoming the sole caretaker of their own and other people’s children. Yet women's needs for reproductive health services, for protection against violence, even for sanitary pads and the equitable distribution of food were long overlooked by aid administrators and refugee leaders.

Historically, relief organizations focused on providing the basics: food, water, and shelter. In 1994, a landmark report by the Women's Commission for Refugee Women and Children (Wulf 1994) focused attention on the serious reproductive health problems facing refugees and the lack of services. That same year, the International Conference on Population and Development (ICPD) in Cairo (www.unfpa.org/icpd/summary.htm#intro) called for greater efforts to protect displaced and refugee populations and ensure their access to health services. In response, refugee relief organizations have collaborated with reproductive health professionals to develop new strategies for meeting the reproductive health needs of displaced populations. Two groups that have led the relief community forward in addressing the reproductive health needs of war-affected populations are the Inter-Agency Working Group on Reproductive Health and the Reproductive Health Response in Crisis Consortium (formerly called the Reproductive Health for Refugees Consortium).

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Bringing reproductive health services to complex emergencies

Early reproductive health interventions were based primarily on assumptions about the reproductive health needs of war-affected populations. However, new research has challenged some of the original assumptions and improved monitoring and evaluation systems are beginning to show the impact of sustained, evidenced-based efforts in reproductive health programs.

At the onset of a complex emergency, the priority is to meet refugees' basic subsistence needs and prevent excess mortality. To address life-threatening reproductive health problems in the aftermath of conflict and flight, reproductive health and relief organizations have developed a Minimum Initial Service Package (MISP). This is a series of activities that requires advocacy, training, and the leadership of a reproductive health coordinator. The supplies needed to implement the MISP are packaged in Reproductive Health Kits made available by the United Nations Population Fund (UNFPA). MISP focuses on preventing and managing the consequences of sexual and gender-based violence; reducing the transmission of HIV by enforcing universal medical precautions and supplying condoms; and providing clean delivery kits and referral for obstetric emergencies. For more information on the MISP, see www.rhrc.org/pdf/fs_misp.pdf.

As a situation stabilizes, minimum services can be expanded to meet the full range of refugees' reproductive health needs and integrated into a primary health care system (Goodyear and Hynes 2001). Such services may be needed for many years until the conflict situation is resolved. Comprehensive services should be based on the results of a thorough needs assessment to ensure that services meet the most pressing needs, are culturally acceptable, and attract community support. Refugees living in camps receive services from clinics and outreach programs within the camps that provide referrals to outside hospitals as needed. When displaced families are dispersed throughout the community, the challenge is to increase the capacity of the existing government health system and supplement it with special services, such as provision of counseling and emergency contraception for women who have been raped.

Research shows that stable populations in long-term camp situations often enjoy better health and access to health care than people in either the country of origin or the host communities. The US Centers for Disease Control and Prevention conducted research in 52 post-emergency phase camps in seven countries. The study concluded that refugees and IDPs in most of these settings had better RH outcomes than their respective host or country of origin populations (Hynes et al. 2002). These results suggest that investing in RH programs can make a measurable impact on the health of war-affected populations. The ability to meet the RH needs in the emergency phase or for populations living out of camps is less well researched and requires further attention (RHRC 2003).

Careful planning is needed to assure the continuity of reproductive health services when refugees eventually return home. Often refugees find that the health care system has been physically destroyed in their absence, with facilities damaged, supplies stolen, and staff members killed. Or they may leave behind readily accessible health care services sponsored by refugee aid organizations to return to a situation where health care is limited and/or unaffordable. Strategies to help returning refugees include training and equipping health workers from the refugee community to accompany them home; rebuilding and restocking hospitals and clinics; and establishing new programs to address refugees' special needs, such as counseling for rape and gender-based violence survivors. (See the program example from Kosovo.)

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Setting priorities

Health experts have identified five areas that comprehensive reproductive health services for displaced populations should address:

1. Safe motherhood: Emergency obstetric care is especially important for averting maternal mortality. Basic obstetric care can be made available in camps, but it is also necessary to create effective referral systems for comprehensive obstetric care.

 2. HIV/AIDS and other STIs: Interventions include ensuring a safe blood supply, strictly enforcing universal precautions, educating people about STIs, distributing condoms, promoting dual protection, protecting against sexual violence, respecting the rights of those who are HIV positive, and providing diagnostic and treatment services. (See the program example from Thailand.)

3. Family planning: Evidence suggests displaced populations make family planning decision based on the same sort of social-economic rationales as populations that are not affected by conflict (McGinn, 2000). Good quality family planning services, including trained providers and a reliable contraceptive supply system, give women greater control over their own fertility.

4. Violence against women: Survivors of gender-based violence need access to counseling, medical care, and referrals to legal services. Programs also can reduce levels of violence by changing community attitudes toward gender-based violence, planning the physical layout of camps and the distribution of essential goods and services with women in mind, and strengthening security. (Also see the program example from Tanzania.)

5. Adolescents: Breakdowns in social norms, loss of parental supervision, lack of schooling and recreational activities, and uncertainties about the future may encourage young refugees to experiment with risky behavior, including unprotected sex. Adolescent refugees also are especially vulnerable to sexual coercion. (See the program example from Africa and RHO's Adolescent Reproductive Health section.)

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Lessons learned

Implementing good quality reproductive health services is difficult in refugee settings. Adequately trained and culturally sensitive staff, equipment and supplies, and infrastructure all are in short supply. Dozens of international, government, and non-governmental organization (NGO) relief agencies provide fragmented and overlapping services to each refugee population. Short-term funding, rapid turnover of relief workers, and the uncertain future of displaced populations jeopardize the continuity of care and the sustainability of services.

Growing experience in the field, however, has identified strategies that can overcome these challenges and help create effective, good quality reproductive health services for displaced services. Lessons learned include:

    • A reproductive health coordinator is essential to advocate for the inclusion of reproductive health services from the beginning of an emergency response, to supply needed technical expertise, and to coordinate interagency efforts to avoid duplication of services.
    • No single model of reproductive health care can be applied to all crisis situations. Services must be tailored to fit the needs and culture of the displaced population and the evidence-based needs created by a specific conflict.
    • More donors must recognize the need for RH services throughout the phases of complex emergencies and provide longer grant periods in order to sustain efforts until normal development processes are resumed and the population regains their independence.
    • The participation of the refugee community (especially women and youth) in the design and implementation of services helps ensure that reproductive health programs are culturally sensitive and respond to the perceived needs of the community. (Also see the program examples from Sri Lanka and the Sudan.)
    • Where resources are limited, programs must prioritize reproductive health interventions based on the importance of the problem, the feasibility of the intervention, and its cultural acceptability.
    • Tapping the experience of the wider public health and development communities can help refugee health programs meet technical standards and offer better quality of care.
    • Collaborating with local health facilities and NGOs, employing technical and educational materials developed for non-refugee populations, and recruiting refugee health workers encourages sustainability.
    • Programs should work to improve procurement and resupply mechanisms for reproductive health equipment and supplies, including contraceptives.
    • The fundamental right of all persons, including war-affected populations, to reproductive health care must be recognized and made operational in complex emergencies and periods of post-conflict transition.

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