|Reproductive Health in refugee situations - An Inter-Agency Field Manual (United Nations Fund for Population Activities - United Nations High Commission for Refugee - World Health Organisation, 1999, 142 p.)|
|Chapter Two: Minimum Initial Service Package (MISP)|
|Components of the MISP|
A qualified and experienced person should be identified to coordinate RH activities at the start of the emergency response. The overall leading agency should be responsible for the designation of such a person, and the person appointed should work under the supervision of the overall Health Coordinator.
RH focal points should be designated within each camp, and within each implementing agency. These health professionals, experienced in reproductive health, should be in post for a minimum of six months, as it is likely to take this long to establish comprehensive RH services.
All relief organisations should, in accordance with their mandates, and within the framework of emergency preparedness and response, train and sensitise their staff on RH issues and gender awareness. (See Terms of Reference for the RH Coordinator at the end of this chapter.)
Sexual violence is strongly associated with situations of forced population movement. In this context, it is vital that all actors in the emergency response are aware of this issue and preventive measures are put in place. The UNHCR Guidelines for Prevention and Response to Sexual Violence against Refugees (1995) should be adhered to in the emergency response. Measures for assisting refugees who have experienced sexual violence, including rape, must also be established in the early phase of an emergency.
Women who have experienced sexual violence should be referred to the health services as soon as possible after the incident. Protection staff should also be involved in providing protection and legal support to survivors of sexual violence.
Key actions to be taken during the emergency to reduce the risk of sexual violence and respond to survivors are:
· design and locate refugee camps, in consultation with refugees, to enhance physical security
· ensure the presence of female protection and health staff and interpreters
· include the issues of sexual violence in the health coordination meetings
· ensure refugees are informed of the availability of services for survivors of sexual violence
· provide a medical response to survivors of sexual violence, including emergency contraception, as appropriate
· identify individual or groups who may be particularly at risk to sexual violence (single female heads-of-households, unaccompanied minors, etc.) and address their protection and assistance needs.
See Chapter Four for further information on elements of prevention and response to sexual violence.
Enforce Respect for Universal Precautions Against HIV/AIDS
Universal precautions against the spread of HIV/AIDS within the health care setting must be emphasised during the first meeting of Health Coordinators. Under the pressure of an emergency situation, it is possible that field staff are tempted to take short cuts in procedures which can jeopardise the safety of patients and staff. It is essential that universal precautions be respected. (See Chapter Five for details on universal precautions.)
Guarantee the Availability of Free Condoms
Availability of condoms should be ensured from the beginning so that they can be provided to anyone who requests them. Sufficient supplies should be ordered immediately. (See Annex 3, Chapter Five, Prevention and Care of Sexually Transmitted Diseases including HIV and AIDS for calculating condom supplies.)
As well as providing condoms on request, field staff should make sure that refugees are aware that condoms are available and where they can be obtained. Condoms should be made available in health facilities especially when treating cases of STDs. Other distribution points should be established so that those requesting condoms can obtain them in privacy.
Provide Clean Delivery Kits for Use by Mothers or Birth Attendants to Promote Clean Home Deliveries
A refugee population will include women who are in the later stages of pregnancy, and who will therefore deliver within the initial phase. Simple delivery kits for home use should be made available for women in the late stages of pregnancy. These are very simple kits that the women, themselves, or traditional birth attendants (TBAs) can use. They can be made up on site and include: one sheet of plastic, two pieces of string, one clean razor blade and one bar of soap. UNFPA also supplies this kit.
A formula, based upon the Crude Birth Rate (CBR), is used to calculate the supplies and services required. With a CBR of three to five per cent per year, there would be some 75-125 births in a three-month period in a population of 10,000. From this, a calculation can be made as to how many kits should be ordered.
Provide Midwife Delivery Kits (UNICEF or equivalent) to Facilitate Clean and Safe Deliveries at the Health Facility
In the early phase of an emergency, births will often take place outside the health facility with- out the assistance of trained health personnel. Approximately 15 per cent of births will involve some complications. Complicated births should be referred to the health centre. The supplementary unit of the New Emergency Health Kit 98 (NEHK-98) has all the materials needed to ensure safe and clean normal deliveries. Many obstetric emergencies can be managed with the equipment, supplies and drugs contained in the NEHK-98. Obstetric complications that cannot be managed at the health centre should be stabilised before transfer to the referral hospital.
Initiate the Establishment of a Referral System to Manage Obstetric Emergencies
Approximately three to seven per cent of deliveries will require Caesarean section. Additional obstetric emergencies may need to be referred to a hospital that is capable of performing comprehensive essential emergency obstetric care. (Refer to Chapters Three and Seven for information on pregnancy and delivery complications.)
As soon as the situation permits, a referral system that manages obstetric complications must be available for use by the refugee population 24 hours a day. Where feasible, a host-country referral facility should be used and supported to meet the needs of refugees. If this is not feasible because of distance or the inability of the host-country facility to meet the increased demand, then an appropriate refugee-specific referral facility should be provided. In either case, it will be necessary to coordinate with host-country authorities concerning the policies, procedures and practices to be followed within the referral facility. The protocols of the host country should be followed, although some variation may have to be negotiated. Be sure there is sufficient transport, qualified staff and materials to cope with the extra demands.
It is essential to plan for the integration of RH activities into primary health care during the initial phase. If not, the provision of these services may be delayed unnecessarily. When planning, it is important to include the following activities:
· The collection of background information on maternal, infant and child mortality, available HIV/STD prevalence and contraceptive prevalence rates (CPR). This information can be obtained from the refugees' country of origin from such sources as WHO, UNFPA, the World Bank and Demographic and Health Survey (DHS). Gathering this information could be the responsibility of the Headquarters of implementing agencies who may have ready access to these data.
· The identification of suitable sites for the future delivery of comprehensive RH services (as described in the remainder of this Field Manual). It is important to address the following factors when selecting suitable sites:
· security both at the point of use and while moving between home and the service delivery point
· accessibility for all potential users
· privacy and confidentiality during consultations
· easy access to water and sanitation facilities
· appropriate space
· aseptic conditions
· An assessment of the capacity of staff to undertake comprehensive RH services should be made and plans put in place to train/retrain staff. Equipment and supplies for comprehensive RH services should be ordered. This will allow comprehensive services to begin as soon as the situation stabilises.