Please note: This archive was last updated in 2005.

RHO archives : Topics : Refugee Reproductive Health

Program Examples

The programs described below illustrate some of the strategies developed by refugee relief and reproductive health organizations to meet the unique reproductive health needs of displaced women.

  • Africa: Using the Girl Guide method to teach adolescent refugees about health issues and to train them as peer educators.
  • Kenya: Improving postabortion care (PAC) in two refugee camps in northern Kenya.
  • Kosovo: Meeting refugees' reproductive health needs in the midst of an emergency and arranging for services after their return home.
  • Sri Lanka: Developing culturally appropriate reproductive health services for internally displaced persons from three ethnic groups.
  • Sudan: A community-based approach to providing reproductive health services to internally displaced people.
  • Tanzania: Reducing levels of gender-based violence in refugee camps and offering medical help, psychological support, and legal services to survivors of violence.
  • Thailand: Reducing HIV transmission in refugee camps by promoting the use of condoms.

Click here to view a list of refugee-related program examples available on other websites.

Africa

With support from the United Nations Population Fund, Family Health International (FHI) and the World Association of Girl Guides and Girl Scouts (WAGGGS) began implementing the Health of Adolescent Refugees Project (HARP) in August 1997. HARP uses the Girl Guide/Girl Scout method to bring basic health education to girls and young women living as refugees. As part of this innovative peer education program, adolescent refugees form Girl Guide groups; earn an Adolescent Health Badge by learning about their own physical, emotional, and mental health needs; and then share this information with their peers. Local health care workers, who receive training from the project, provide information and services to the Girl Guide groups. FHI and WAGGGS have created an adolescent health curriculum, trained refugee women as Guide leaders, and established dozens of new Girl Guide groups in refugee communities in Egypt, Uganda, and Zambia.

The primary goal of the program is to give adolescent refugees the information they need to make good decisions about behavior affecting their health. At the same time, HARP develops health awareness, self-confidence, and leadership skills among the women refugees who serve as Guide leaders.

The health curriculum at the core of the program covers a broad range of issues confronting adolescents and is tailored to the special needs of refugees. It is divided into three age levels that correspond to levels of Girl Guide membership. The youngest group (ages 7 to 10) learns about the human body, including the male and female reproductive systems; changes during puberty; building self-confidence and self-esteem; relationships with family, friends, and the community; preventing disease; hygiene; and nutrition. The middle group (ages 11 to 14) covers these topics in more detail and also learns about domestic violence, STIs, and preventing pregnancy through abstinence and family planning. Information on healthy pregnancies and how to raise healthy children are added to the curriculum for the oldest girls (ages 15 and up).

Girls of all ages also learn how to become effective peer educators. For example, the curriculum covers the use of drama, music, and dance to deliver messages and teaches how to organize group events. To earn their Adolescent Health Badge, girls must complete a flipbook with their own artwork and text on curriculum topics, as well as several other required activities. Later the flipbook serves as the girls' key peer education tool. After earning their badge, the girls conduct individual and group peer education activities in their communities, using materials they have made themselves, to earn bronze, silver, and gold certificates of achievement.

Collaboration between Guide groups and the local health care workers who provide services to refugees is central to the HARP program. Local health care workers attended the April 1998 training workshop along with Guide trainers and national project coordinators. After the Guide groups were launched, the health workers remained available to teach the girls and leaders about medical issues and to offer youth-friendly services to adolescents in need.

For the first phase, HARP established 20 Girl Guide groups, each with 30 adolescents, in refugee communities in Uganda and Zambia. The program has faced greater obstacles in Egypt, where refugees are not concentrated in particular settlements and are frequently relocated. Because of constant turnover in the refugee population in Egypt, the project continued to enroll new leaders and girls, each of whom participated for as long as she was able. There were about 100 girls working on Adolescent Health Badges in Egypt at the time of the project evaluation in January 2000.

While parents and community leaders initially were reluctant to let girls participate, they have since become strong supporters of the program as they have realized how important and helpful the curriculum contents are. The Girls Guides' peer-education efforts, including skits and songs, have been received enthusiastically by other young people.

The January 2000 evaluation of HARP documented multiple positive impacts on the girls, the adults who work with them, and the larger refugee community. The girls all learned something about their health although the project time was too short to allow for data on outcomes such as reduced pregnancy. Practical information, such as learning about nutrition, puberty, and sanitation, was more popular and more thoroughly assimilated than technical information, such as the physiology of the menstrual cycle. Anecdotal evidence suggests an increase in adolescents accessing health services.

The impact of the project has gone beyond health issues, however: participating in the project has literally changed the girls' lives. They have been given a place to interact with adults who care about them, they have become part of a special group, and they have gained knowledge and skills that are relevant to their lives—not just in health, but in areas related to being a Girl Guide, such as teamwork and leadership. Participating girls have recognized the importance of education and stayed in or even returned to school. Adults living and working with the girls note that they are more self-assured, more assertive, and more self-confident. The girls themselves are able to talk openly and fluently about how HARP has made them feel more able to cope with the challenges in their lives and put them in a position to help others.

HARP also has had a positive impact on the adults involved. They are recognized as experts within their communities, they have more self-confidence, and they have gained knowledge and skills which they use to help those around them.

At the community level, the girls have spread key health messages far and wide by performing songs, poems, and role-plays for their schools and villages and also for camp-wide events such as Africa Refugee Day and World AIDS Day. The project also has helped build stronger, more self-reliant communities. The communities involved have felt a real sense of pride as they have watched the development of the girls. They have come to recognize the importance of educating girls and view them as a resource for the whole community.

All three countries are continuing with HARP in various ways. In Zambia, funding from UNAIDS and the Reproductive Health for Refugees Consortium has enabled HARP to grow. The program has been introduced to other refugee camps across Zambia, and the curriculum's HIV/AIDS coverage has been expanded. In response to requests from community members who felt their sons also needed this sort of education, the Guides approached the Boy Scouts in Zambia to open the program up to boys. In Uganda, funding from UNHCR has allowed HARP to continue in the original site, giving more young refugees the opportunity to take part. In Egypt the National Girl Guide Association is supporting the Guide groups set up for HARP and integrating them into Egyptian Guiding.

For more information about HARP, check the WAGGGS website (www.wagggsworld.org/aroundtheworld/projects/harp/index.html) or contact:
Matthew Tiedemann, Family Health International, P.O. Box 13950, Research Triangle Park, NC 27709 USA
Telephone: 919-544-7040 ext. 210; Fax: 919-544-7261; Email: [email protected]

Lindsay Gilbert, World Association of Girl Guides and Girl Scouts, World Bureau, 12c Lyndhurst Road, London NW3 5PQ United Kingdom
Telephone: 44-171-794-1181; Fax: 44-171-431-3764; Email: [email protected]

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Kenya

Ipas and the National Council of Churches of Kenya (NCCK) launched a project in July 1998 to improve postabortion care (PAC) in two refugee camps in northern Kenya as part of UNFPA's Program for Expanded Reproductive Health Services in Refugee Camps. Together, the Dadaab and Kakuma camps shelter about 180,000 Somali, Sudanese, and other refugees.

These long-standing camps already had a network of reproductive health services overseen by NCCK and implemented by international NGOs. However, women refugees had limited access to PAC services. Because incomplete abortions were treated with dilation and curettage (D&C), only physicians could provide the service. A single physician at the mission hospital in Kakuma provided PAC services, while women at Dadaab had to be referred outside the camp to local hospitals. In addition, links with postabortion family planning counseling and services and other reproductive health services were weak.

A baseline needs assessment found that the refugee communities, health care providers, and health administrators were enthusiastic about improving PAC services. The presence of mid-level health care providers at the refugee camps created an opportunity to decentralize care, while manual vacuum aspiration (MVA) offered a low-technology alternative for treating incomplete abortions. By training non-physicians in MVA and other skills, PAC services could be integrated into existing reproductive health services at the refugee camps using the infrastructure and providers already available.

All of the mid-level providers at the two refugee camps (including four medical officers, four clinical officers, and ten nurses) attended a one-week training session on PAC, along with reproductive health coordinators from UNHCR and NCCK. The providers received theoretical and practical training in MVA, counseling skills, management of complications, and provision of family planning. The course also encouraged linkages with other reproductive health information and services. Both the training course and implementation of services were conducted in collaboration with the local government and the NGOs operating in the camps: the International Rescue Committee (IRC) and Medecins Sans Frontieres (MSF).

After training, comprehensive PAC services were established at the maternity clinic in Kakuma and at all three hospitals in Dadaab. Monitoring visits one year later found that efficient, timely, and comprehensive PAC services were being offered at Kakuma with the support of everyone involved. During the first 16 months after training at Kakuma, 141 women received postabortion care as well as related family planning counseling. Implementation proceeded more slowly at Dadaab due to lack of support from a new head of medical services, who had not participated in the training. At Dadaab, 51 women received PAC services over the first nine months; from 40 percent to 80 percent of these patients also received family planning counseling. No complications were reported at any of the sites.

Rapid turnover of medical staff, which is typical of refugee settings, posed a major challenge at both refugee camps. On-the-job training for new staff quickly became necessary to sustain PAC services, both to pass along technical skills and to orient administrators and providers to the need for services and their benefits. This on-the-job training is offered informally by experienced providers, using educational materials distributed at the original training session. A second challenge is the lack of client information and education about available reproductive health services, including postabortion care.

Despite these challenges, the programs at Kakuma and Dadaab have succeeded in:

  • reducing the waiting time for women suffering complications of abortion,
  • reducing the need for distant referral services,
  • increasing the provision of postabortion family planning, and
  • improving the quality of reproductive health care for women refugees.

PAC services are continuing to function smoothly where administrators are supportive and on-the-job training is available for new staff.

Lessons Learned

  • Comprehensive reproductive health services for refugees should include abortion-related care.
  • Offering decentralized PAC services at the health delivery sites where refugee women normally seek care is feasible, reduces resources used, increases access, and speeds the provision of care.
  • By involving mid-level health personnel and using appropriate technology (that is, MVA), refugee reproductive health programs can meet the need for PAC services even where doctors and operating theaters are lacking.
  • Where staff turnover is high, on-the-job and refresher training is essential to ensure that services continue even as personnel changes. Such training should cover the need for and benefits of comprehensive PAC services as well as technical information.
  • Continued attention must be paid to infection prevention and proper instrument processing.
    Interventions should include community education on abortion-related care and other reproductive health services.

For additional information about this program, please contact:
Joan Healy, Vice President for Training and Service Delivery Improvement, Ipas, 300 Market Street, Suite 200, Chapel Hill, NC 27516, USA.
Telephone: 919-967-7052; Fax: 919-929-7687; Email: [email protected]

For more information about Ipas' efforts to offer abortion-related services to displaced peoples, see:
Falk, S. Reproductive health in crisis situations—lessons from the field. Dialogue 5(1) (March 2001). Available at: www.ipas.org/publications/en/dialogue/volume5_number1.pdf.

Lehmann, A. Assessment Tools for Implementing Postabortion Care in Refugee Reproductive Health Programs. Chapel Hill, North Carolina: IPAS (December 2000). Available at: www.ipas.org/publications/en/assessment_tools_postabortion_refugee.pdf.

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Kosovo

The sudden flight of almost one million refugees from Kosovo to Albania, Macedonia, and Montenegro in the spring of 1999 tested the MISP approach to refugee emergencies developed by reproductive health advocates. UNFPA became the reproductive health coordinating agency during the emergency phase of this refugee crisis. The agency drew on logistical support and local knowledge from its own office in Tirana and financial assistance from donors to respond promptly and efficiently. A consultant was hired to coordinate and facilitate the reproductive health activities of international agencies, national authorities, and local nongovernmental organizations (NGOs). In addition, a psychologist was hired to investigate and document the extent of sexual violence, including systematic rape. UNFPA supplied enough emergency reproductive health kits to local maternity hospitals and NGOs to meet the needs of 600,000 refugees for a three- to six-month period; it also supplied sanitary pads and underwear. The cost of the operation, about US$1.1 million, was kept relatively low because UNFPA's Tirana office was able to reduce administrative and logistical costs and because reproductive health services were integrated into primary health care.

With the end of the conflict in June 1999, the Kosovar refugees returned home as rapidly as they had fled, and relief agencies faced the challenge of rebuilding the health system to meet the reproductive health needs of the returnees. Rates of infant mortality, abortion, and infertility all were high. Health facilities were looted and destroyed during the war, and women carried a heavy burden from the sexual violence associated with it. Pre-existing conditions also contributed to reproductive health problems, however. For over a decade, the central government had relegated the Kosovo Albanians to a parallel health system which was starved of new equipment, supplies, and medical education. There was no tradition of preventive gynecological care: women did not visit a doctor before labor, and family planning was viewed as a tool of state genocide. Finally, the status of women was low, and notions of honor meant that women could not admit to rape or other sexual violence.

Returning refugees had an immediate need for emergency supplies and equipment. However, the conflict and ensuing breakdown in services also created an opportunity for long-term improvements in the quality of reproductive health care in Kosovo by updating health care practices and changing popular attitudes and expectations. Two months after the territory was freed, a group of local clinicians drew up a comprehensive reproductive health policy for Kosovo with international assistance. This policy is based on a human rights framework and calls for universal access to a full range of reproductive health services. Physicians, women's groups, and other key players have established a National Committee for Healthy Families to advise governing authorities about reproductive health issues.

With 300 NGOs and international agencies working in Kosovo, simply dividing responsibilities for reproductive health care and coordinating efforts posed an enormous challenge. One of the first tasks was getting generators, heat, running water, food, and blankets into maternity units. UNFPA and CARE also held five-day courses to sensitize 1,400 health care staff to essential reproductive health care as a first step toward changing their professional culture and upgrading their training. Sexual violence poses a continuing challenge: basic gynecological exams and counseling hold hidden pitfalls for women who have suffered from violence. Working with local organizations has been essential to gain the trust of these victims.

For further information, contact: Dr. Wilma Doedens, UNFPA Senior Analyst for Emergency Relief Operations, P
Telephone: 41-22-979-9314/15; Email: [email protected]

This case study is based on: Pierotti, D. Albania and Macedonia: UNFPA action in reproductive health for Kosovar refugees, Entre Nous 46:8-9 (Spring 2000); and  Bower, H. Kosovo: reproductive health in emergencies, Entre Nous 46:10-11 (Spring 2000).

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Sri Lanka

Since 1995, Population Services Lanka (PSL) has been offering reproductive health services to internally displaced persons in three districts of northeastern Sri Lanka in partnership with Marie Stopes International (MSI). A combination of mobile and static clinics provide comprehensive services, including prenatal and postnatal care, information on nutrition and hygiene, a full range of temporary and permanent family planning methods, and STI and HIV/AIDS services.

Designing culturally acceptable services is challenging because the clinics serve three ethnic groups: Tamil, Muslim, and Sinhalese. To ensure that materials and activities meet the needs and preferences of the internally displaced persons, program teams have worked closely with representatives from the internally displaced person community to review project design and implementation at all stages of the process and have appointed doctors and staff members from each ethnic group. Based on input from the community representatives, for example, program managers changed the schedule at the health center at Puttalam, opening on Sundays which is convenient and culturally appropriate for the predominantly Muslim internally displaced persons who live nearby. Participatory monitoring and evaluation systems help ensure that services continue to meet the changing needs of the community and are culturally appropriate

Program managers also have worked to increase the accessibility of services. Careful monitoring and community consultation revealed that internally displaced persons were more likely to access and continue using health services if mobile clinics were no further away than a 10- to 15-minute walk. PSL also has identified and trained female volunteer health educators from each ethnic group. These Community Health Promoters (CHPs) visit homes on a monthly basis to raise awareness of reproductive health issues and act as coordinators for outreach service teams.

Community participation in the design, implementation, and monitoring of services has contributed to the program's success. The Tamil, Muslim, and Sinhalese communities now find a range of sexual and reproductive health services acceptable. Increasing numbers of internally displaced persons are seeking reproductive health care, including STI services, now that clinics are closer, operating hours are more convenient, and health care workers from their own ethnic group are available. The rates of contraceptive prevalence, prenatal care, and postnatal care are high, and infant health statistics have improved.

Although the program is focused on internally displaced persons, it has not ignored the reproductive health needs of the host population. Clinic services are available to local people as well as to internally displaced persons. This has reduced discord between the two communities. Since local people are better able to pay for health care than internally displaced persons, offering services to the host population has helped subsidize the program.

Working in a situation of conflict has created several obstacles to the reproductive health program in Sri Lanka. It is difficult to recruit staff with the necessary qualifications to provide a full range of sexual and reproductive health services. Ethnic tensions complicate contacts with ministry and government officials. The government's priority is providing primary health care to the people caught up in the conflict, but primary health care programs may not include comprehensive reproductive health services.

Lessons Learned

  • Training representatives from the displaced community to work as community health promoters provides internally displaced persons with a small source of income and status during displacement and beyond. It also ensures that the wider community will continue to have access to reproductive health information when they return home.
  • Extra care, including occasional specialist technical support, is needed to ensure that quality of care is not compromised when minimum, emergency services for refugees and internally displaced persons are expanded to include a comprehensive set of reproductive health services.
  • Collaborating with government health facilities and with other NGOs that provide services to internally displaced persons facilitates service provision and provider training.
  • Health committees, consisting of representatives from the internally displaced person community, can ensure that program materials and services are both appropriate and culturally acceptable.
  • Offering services to the host population minimizes discord and helps fund health care for refugees and internally displaced persons.
  • In areas of conflict, it is important that key program personnel are acceptable to the authorities as well as to the communities receiving services.

For additional information, please contact:
Atula Nanayakkara, Chief Executive, Population Services Lanka, 155 Kirula Road, Narehempita, Colombo, Sri Lanka
Telephone: 00-941-581035; Fax: 00-941-854643; Email: [email protected]

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Sudan

Since 1999 the American Refugee Committee (ARC) has operated a comprehensive reproductive health program in Southern Sudan for displaced persons and local residents affected by war. ARC's program aims to reduce high maternal/child mortality, treat and prevent sexually transmitted infections (STIs), increase awareness of sexual and gender-based violence, and improve family planning and child-spacing options.

ARC's reproductive health program encourages the community to take as much ownership and responsibility as possible. All members of the reproductive health team are local residents. All of the workshops and training activities are held in churches, government buildings, homes, or other community facilities. Many community leaders, including officials, church leaders, and chiefs, are involved in the program, encouraging local people to participate, promoting healthy behaviors, and lending bicycles, facilities, and other needed items. In fact, community requests for more reproductive health services and information have driven the rapid expansion of the program in size and scope.

So far, the program has set up four reproductive health clinics in southern Sudan, including two in camps for internally displaced persons. The reproductive health clinics are readily accessible to most people, but primary health care units in more remote locations also promote awareness of HIV/AIDS and safe motherhood. In addition, HIV/AIDS awareness is increasingly being integrated into primary health care outreach activities, which have focused on immunizations against childhood diseases and tetanus toxoid immunizations for women of childbearing age. The program's major focus is on safe motherhood, STIs, and HIV/AIDS. Activities include provision of contraceptives (condoms, oral contraceptives, injectables) and treatment of diseases related to reproductive health, including STIs. ARC also emphasizes "universal precautions"—a comprehensive strategy for preventing transmission of blood-borne diseases

ARC has trained local community members to work as reproductive health promoters and supervisors. These staff are recruited from the resident population and the camps, and they receive a small cash incentive in return for their work. The 38 promoters currently working for the program raise community awareness, provide reproductive health education and counseling, make clinic referrals, and dispense condoms during home visits and outreach sessions in 3 camps for the internally displaced and in over 20 villages. Fourteen community health workers have been trained as reproductive health supervisors. They manage the reproductive health clinics and provide services to clients, supervise promoters, and conduct community workshops. Training lasts several weeks and is followed up with refresher sessions as needed. To reinforce the training, ARC has created a comprehensive reproductive health binder and distributed it to all health units and health centers, where it is available for consultation by staff.

Each year, ARC officers also conduct three to five training courses for traditional birth attendants (TBAs), with about 170 trained to date. Because many of the TBAs have limited education, most of the training is pictorial or oral, with hands-on practice. Training for these traditional midwives focuses mainly on safe motherhood and universal precautions, along with HIV/AIDS awareness. TBA training has helped to reduce complicated births, maternal deaths, and infant mortality.

ARC's reproductive health program has made a good start under difficult conditions. Southern Sudan, which has been plagued by a long civil war, is a security risk area. The ongoing conflict there tends to disrupt not only reproductive health activities, but the lives of the people themselves. There also are strong cultural practices that conflict with good reproductive health practices, such as the acceptance of forced sex and male-centered decision-making about abstinence or condom use. To find culturally appropriate solutions for this problem, ARC turns to the community, asking astute and influential local people how best to deliver reproductive health messages, dispel myths and misconceptions, or overcome a particular custom. With their input and the assistance of local artists, the reproductive health program has produced posters, flipcharts, t-shirts and other IEC materials for distribution to health facilities and communities.

Results of a knowledge, attitudes, and practice survey in the area and several focus groups have been encouraging. They suggest that the reproductive health program has helped educate many local people about family planning, safe motherhood, STIs, and sexual and gender-based violence. Changes in condom use, family planning use, behaviors related to safe motherhood, treatment of STIs, and reporting of cases of sexual and gender-based violence have been observed. Local people also support further expansion of STI and HIV/AIDS services and education activities, particularly in the areas of counseling and testing for HIV/AIDS.

Lessons Learned

One lesson learned has been the need to move forward slowly and carefully, given the sensitivity of reproductive health topics in these and other communities. It takes time for true awareness to take hold and for beliefs to change. Program activities cannot be rushed to meet some externally imposed deadline.

A second lesson is that every community is different and must be approached individually. Generalizations cannot be used much, even within similar cultural groups.

In the coming years, ARCs reproductive health program plans to expand into a neighboring county, to collaborate more closely with local health partners to strengthen and integrate reproductive health services, and to recruit and train local assistants for the Reproductive Health Coordinator. Ultimately, the goal is to create a fully sustainable program by training local people to act as technical advisors and managers for the program and by finding local funding or developing income-generation activities.

For more information, please contact:
Paula Dickey, Country Director, ARC International, Sudan, P.O. Box 7868, Kampala, Uganda
Telephone: 256-41-349-091, 094, 095, or 096; Fax: 256-41-349-147; Email: [email protected]

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Tanzania

The Tanzania Sexual and Gender Based Violence (SGBV) Program of the International Rescue Committee (IRC) has served Burundian refugees in western Tanzania since late1996. The program's interventions are designed both to prevent sexual and gender-based violence and to respond to the needs of survivors.

From the start, the program worked closely with elected women's representatives to assess the extent of violence and design a culturally appropriate response. After attending a five-day orientation workshop, the women's representatives introduced the project to women in their community during a series of block meetings. These trusted, respected women leaders were able to overcome survivors' fears of being ostracized and punished for speaking out about their experiences. Initially, 68 women came forward with stories of violence. In-depth interviews with these survivors revealed that, in addition to rape, domestic violence, sexual harassment, and abduction and forced marriage during adolescence were problems for refugee women. The interviews also showed that sexual violence affects young girls and boys (under age 12) as well as the women assumed to be targets.

Based on these interviews, the women's representatives designed and conducted a survey and thorough needs assessment to demonstrate that sexual violence was a widespread problem in the camp. The findings encouraged refugee women to think about how the breakdown in family, community, and government structures had put them at risk since they became refugees and prompted them to demand change. Since then, the program has instituted a variety of interventions.

1. Drop-in Centers. After disseminating the results of the survey to the community, the women's representatives decided that a 24-hour support service was needed for survivors of violence. Therefore, the sexual and gender-based violence program created drop-in centers attached to the maternity wards and maternal and child health clinics in the camps. The centers give women a safe, confidential setting to gather regularly, and to access services without identifying themselves as survivors of violence.

When women seek help in the drop-in centers, project staff first meet their critical medical and protection needs. Staff provide psychosocial counseling on how to continue living in the community; facilitate medical examinations and treatment for trauma, sexually transmitted infections including HIV/AIDS, and pregnancy; offer referrals to social workers when a woman wishes to apply for family separation; and assist those intending to take legal action. Essentials such as soap, clothes, and food also are provided to the most needy. All survivors receive an open invitation to return as often as they want to discuss the incident. The Centers provide services on a 24-hour basis and can offer safe shelter during the night.

Seven trained women's representatives and four male block leaders provide these services, with support from three national program staff. In addition, three SGBV health personnel conduct forensic examinations, provide medications, and complete appropriate legal documents.

Services are provided under strict confidentiality, with respect to the survivors and their concerns and needs. As a result, the program has won the confidence of the beneficiaries and the survivors who freely report incidents without feeling stigmatized. The refugee community has labeled the centers in their own language: they are called "Agateka" and "Butungane," referring to a place of peace and harmony.

2. Community awareness-raising. After establishing the drop-in centers, women's representatives decided that the next step was to reach out to men in the camps. Men's support is needed to give the program credibility, to foster a community sense of responsibility for safety to prevent violence, and to strengthen community structures that could address the issue of violence. Today, trained community leaders including the men who lead camp blocks as well as religious leaders, teachers, and women's representatives plan, organize, and implement SGBV awareness activities. Sensitization on sexual violence is also done at camp reception centers to create awareness of the issues and available services.

3. Social forums for women and girls. Following requests by women for a forum to discuss their issues as women and as refugees, the program helped create social forums for women and girls. During the initial discussions women identified the need for sanitary pads. Through donations from Refugees International, the USAID Bureau for Population, Refugees and Migration, and UNHCR, red flannel materials were made available for them to hand knit into sanitary pads in their preferred designs.

The program uses these forums to disseminate educational messages, create a friendly environment for beneficiaries and staff to interact, orient new beneficiaries to the centers, and stay in contact with previous beneficiaries.

4. Training and advocacy. Staff organize and facilitate training on sexual and gender-based violence issues for other service providers and organizations. The program conducts some advocacy through camp, district, and regional sexual and gender-based violence coordination meetings, sharing reports, and the circulation of a quarterly IRC-SGBV newsletter.

Agencies, NGOs, and government institutions work hand-in-hand with the program to prevent and respond to sexual and gender-based violence in the refugee camps. In April 2000, IRC Tanzania participated in standardizing SGBV protocols, guidelines, and practices. This process defined the roles and responsibilities of each of the partners addressing sexual and gender-based violence and spurred proactive action. UNHCR is following protection issues closely through a lawyer and an SGBV Field Assistant. The health program has identified SGBV focal persons to coordinate with the program. Police have been trained and are fully involved in supporting survivors and the organizations which respond to incidents.

The program's accomplishments are numerous, and it has grown tremendously since its start in 1996. Initially the program operated in four camps: Kanembwa, Mkugwa, Nduta, and Mtendeli. As a result of capacity-building efforts, responsibility for activities in Kanembwa and Mkugwa camps was transferred to UMATI, a Tanzanian organization, in 1999. In February 2000 the program initiated activities in the newly established Karago camp. Today, the IRC program serves approximately 150,000 Burundian refugees. The program also has created an SGBV databank, established a quarterly newsletter, and created other materials with beneficiaries and program partners.

Since April 2000, IRC has provided services to 231 survivors of sexual and gender-based violence and 890 refugees seeking help with other problems, such as minor family disputes. Rape is the most common type of sexual and gender-based violence reported: of the SGBV survivors, 33 percent experienced rape in or around the camps, 13 percent reported rape before arriving in camp, and 13 percent were the victims of attempted rape. Another 31 percent of the survivors reported gender-based violence, 7 percent were sexually harassed, and 2 percent were involved in forced marriages.

Over the course of the program, refugee women have been empowered to assume a more active role in the community and to seek solutions to their problems. At the same time, communities have become more aware of the issue of sexual and gender-based violence and relevant Tanzanian laws. Rape, domestic violence, and early marriage are serious criminal offenses that are now considered community problems rather than domestic matters. Men and women have joined together to reach consensus on how assailants should be punished and to mobilize the police and court systems to apprehend and prosecute perpetrators. As a result, women are more likely to report incidents and press charges.

Despite its accomplishments, the program still experiences various challenges:

  • Counselors must cope with high levels of stress from heavy workloads and the serious emotional nature of incidents.
  • Survivors and counselors experience threats by perpetrators and some community members with negative attitudes toward program efforts.
  • Survivors sometimes withdraw from the legal process.
  • There is a lack of meaningful activities in the camps.
  • The community is unstable with frequent family disintegration.
  • Funding is limited.

Lessons Learned

The sexual and gender-based violence program holds lessons that go beyond anti-violence initiatives and refugee programs:

  • Community participation in needs assessment and program design builds trust, fosters a desire for change among local people, and leads to the creation of sustainable solutions that reflect local values and are within the community's own resources.
  • Working through existing community organizations can accelerate and expand a program's impact. However, the program's success will vary depending on the energy and commitment of community leaders.
  • Research on sexual violence should not be conducted unless there are services available to which women can be referred for help.
  • Rapid survey techniques are not appropriate for sensitive topics such as sexual violence. Interviews are better suited for quick, initial research.
  • The nature of their job puts sexual and gender-based violence counselors at high risk of burnout; they need help coping with the stress of their work situation.
  • Sexual and gender-based violence programs must involve men to ensure that the community and local government structures address the issue seriously.

For additional information about this program, please contact:
Mr. Francis Selasini, SGBV Program Manager, IRC Tanzania
Email: [email protected]

Mary Otieno, Reproductive Health Senior Technical Advisor, International Rescue Committee, 122 East 42nd St., New York, NY 10168-1289, USA
Telephone: 212-551-3066; Fax: 212-551-3185; Email: [email protected]

More information about the program can be found in the following reports: Pain Too Deep for Tears by Sydia Nduna and Lorelei Goodyear (September 1997), A Safe Space Created by and For Women by Sydia Nduna and Darlene Rude (March 1998), Evaluation of the Sexual and Gender-Based Violence Program by Silvia Gurrola (April 1999), and Sexual and Gender-based Violence Program Summary, Kibondo, Tanzania (December 2000). All four reports are available online at the IRC website (www.theirc.org/where/index.cfm?locationID=41).

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Thailand

With the flight of Karen refugees from their remote villages in Burma to large refugee camps on the Thai border has come an increased risk of HIV/AIDS. At the Nu Po refugee camp, 46 percent of the nearly 9,000 residents fall in the reproductive age group of 15 to 45 years. Despite changes in their lifestyle and health risks, however, refugees attitudes remained the same: refugees denied that they were at risk of HIV/AIDS and were reluctant to discuss the "dirty" subject of condoms. Camp leaders opposed sexual health education and condom distribution, and health workers felt uncomfortable discussing these sensitive topics. In January 1999, the Community Health Education (CHE) program of ARC International/Thailand launched a campaign to prevent the spread of HIV/AIDS transmission by increasing the use of condoms at Nu Po camp.

One aim of the project was to have community members help plan and implement activities, as well as participate in them. However, convincing the refugees that they were at risk of HIV/AIDS and persuading the community to accept and participate in condom promotion activities posed a major challenge. When the project began, the Nu Po camp hospital had not officially reported any cases of HIV/AIDS, and group discussions found that most refugees were not practicing high-risk behaviors such as drug abuse and multiple partners. Thus it was essential to find data that clearly demonstrated the HIV/AIDS risks in the community, the need for sexual health education, and the importance of condom use. Equally important was convincing community leaders and health workers to support the project.

Health workers were the first group in the community to accept the need for condom use and sexual health education. However, they required training to overcome their negative attitudes toward condoms, to make them feel comfortable handling condoms and discussing sexual issues, and to increase their knowledge of STIs and HIV/AIDS. Trainers discussed the prevalence of HIV/AIDS and social conditions in Nu Po camp as well as the situation in Thailand and Burma. They also presented technical information on the STIs, HIV/AIDS, and family planning methods.

Womens groups were the next group to show support for the condom promotion project. Their interest was stimulated both by friends who were health workers and by a womens rights project that encouraged them to protect their reproductive health. Then the condom promotion project garnered support among men, including camp committee members, until it reached the general community. To ensure community support and participation, staff members met monthly with health worker teams, womens groups, youth groups, and the camp committee. During these meetings, they shared information on the HIV/AIDS situation in the camp and surrounding countries, explained their plans for HIV/AIDS prevention and condom promotion activities, and asked for advice and help from community members.

Community health education has been a central element of the condom promotion campaign. In collaboration with the camp health affairs department, project staff conducted an intensive three-week training program for a representative from each of the 15 sections of Nu Po camp. These trainees then carried the message throughout the camp, using posters and videos to conduct classes for adults and young people on sexual health, STIs and HIV/AIDS, and condoms. All high school students and young people in the camp have received one week of instruction, including a demonstration of how to use condoms. In addition, about 100 supporters paraded around the camp on World AIDS Day to raise community awareness; they wore AIDS ribbons and condom T-shirts, waved AIDS posters, and handed out condoms. After the parade, games and contests were held at the community center.

Staff members distribute condoms from their homes in every section of the camp; condoms are also available at health service facilities. The project stocks various types of condoms based on community preferences, and staff members collect information on recipients satisfaction with them. To learn about and address personal concerns about condom use, staff gathered a group of 50 refugees (more male than female) to share experiences and ask questions. Project staff now routinely discuss condom practice with individuals and small groups of clients when they come for condoms and during home visits. In addition, condom data-collection forms have been developed to gather information on recipients by gender, marital status, location within the camp, prior condom use, and number of condoms received. These data are used to monitor and analyze the pattern of condom distribution.

Project staff also educate refugees on family planning methods, concentrating on three groups of refugees identified in an initial needs assessment: couples who are not using any type of family planning, women experiencing side effects from hormonal contraceptives (injections and the pill), and newly married couples. Staff members also recommend condoms for birth control and/or disease prevention to women who have just given birth, breast-feeding women, and men who have had vasectomies. All of the refugees are referred to the camps family planning clinic for further assistance.

The condom promotion campaign has encountered some resistance from the community. For example, the community does not allow condoms to be openly distributed in public; thus condom distribution remains limited to health service facilities and staff members homes. The community is especially sensitive about young people. While project staff are permitted to teach high school students and other young people about HIV/AIDS transmission and prevention, they are not allowed to distribute condoms to youth or single people.

An evaluation conducted in August 2000, 20 months after the project began, documented multiple project achievements:

  • Community representatives have conducted classes on HIV/AIDS prevention and condom use throughout the camp and have reached both adults and young people.
  • Refugees living in Nu Po camp are more familiar with and more willing to openly talk about condoms.
  • Condoms are available from staff members in every section of the camp. Over 10 percent of refugees of reproductive age have registered to receive condoms, and over 7,000 condoms have been distributed.
  • Almost equal numbers of men and women have registered for condoms, and many wives request condoms for their husbands.
  • Some 60 or 70 refugees have switched to condoms as a family planning method after experiencing side effects with hormonal contraceptives. Before the campaign, very few family planning clients in Nu Po chose to use condoms.
  • The camp hospital has begun to share information on suspected cases of HIV/AIDS, because there is less concern that refugees might injure or expel community members infected with HIV/AIDS.

Some project objectives have not yet been fully met. Many people still feel too embarrassed to ask for condoms. In order to increase accessibility, staff are giving refugees as many condoms as they request, in hopes that they will share them with others who feel too uncomfortable to ask. On average, regular users receive 15 to 30 condoms monthly. The effort to change attitudes, increase HIV/AIDS awareness, and promote community acceptance of condoms also continues, with ongoing promotional activities, adult classes, and youth workshops. Focus groups and community meetings are planned to explore how the project can strengthen its impact.

Lessons Learned

Many lessons have been learned during the condom promotion campaign at Nu Po refugee camp. Experience has highlighted the need to:

  • Identify change agents (including gatekeepers, key informants, community representatives, and both formal and informal leaders) who can help spread information, plan, and implement the project.
  • Participate in community events, share information on needs and problems with the community, and use community meetings as a forum to address project activities.
  • Make community visits and hold focus groups to gather information on local beliefs and problems; consider cultural sensitivities during project development; and collect and respond to community feedback throughout the project.
  • Listen to and learn from local people, identify their strengths and weakness, and work with them to reinforce strong areas and change weak areas.
  • Select project staff with maturity and good communication skills to network with community leaders, working groups, and camp residents and to deal with conflicts that arise during implementation.
  • Review prior research to find relevant conceptual frameworks and educational principles, and build on their lessons learned to design an effective campaign.
  • Conduct a needs assessment before starting the project, and develop data collection and reporting systems to monitor project implementation and evaluate its progress.

For more information, please contact:
Gary Dahl, Southeast Asia Director, ARC International, 37 Soi 15, Soi Somprasong 3, Petchburi Road , Bangkok 10400, Thailand
Telephone: 662-252-5186, 653-8576, or 254-5365; Fax: (662) 253-2899; Email: [email protected]

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