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Reproductive health: a right for refugees and internally displaced persons.

Abstract: Continued political and civil unrest in low-resource countries underscores the ongoing need for specialised reproductive health services for displaced people. Displaced women particularly face high maternal mortality, unmet need for family planning, complications following unsafe abortion, and gender-based violence, as well as sexually transmitted diseases, including HIV. Relief and development agencies and UN bodies have developed technical materials, made positive policy changes specific to crisis settings and are working to provide better reproductive health care. Substantial gaps remain, however. The collaboration within the field of reproductive health in crises is notable, with many agencies working in one or more networks. The five-year RAISE Initiative brings together major UN and NGO agencies from the fields of relief and development, and builds on their experience to support reproductive health service delivery, advocacy, clinical training and research. The readiness to use common guidance documents, develop priorities jointly and share resources has led to smoother operations and less overlap than if each agency worked independently. Trends in the field, including greater focus on internally displaced persons and those living in non-camp settings, as well as refugees in camps, the protracted nature of emergencies, and an increasing need for empirical evidence, will influence future progress. (c)2008 Reproductive Health Matters. All rights reserved.

Keywords: refugees, internally displaced persons, conflict and crisis settings, humanitarian response

Resume

Les troubles politiques et civils dans les pays a faibles ressources soulignent le besoin de services specialises de sante genesique pour les personnes deplacees. Les femmes deplacees souffrent en particulier d'une mortalite maternelle elevee, de besoins insatisfaits de planification familiale, des complications d'avortements non medicalises et de la violence sexiste, ainsi que d'IST, notamment le VIH. Les institutions d'aide humanitaire et de developpement et les Nations Unies ont prepare du materiel technique et introduit des changements politiques positifs dans les environnements de crise et elles s'efforcent d'ameliorer les soins de sante genesique. Des manques importants n'en demeurent pas moins. La collaboration pendant les crises est bonne, beaucoup d'institutions travaillant dans un ou plusieurs reseaux. L'initiative quinquennale RAISE rassemble les principales institutions des Nations Unies et ONG specialisees dans l'aide humanitaire et le developpement, et se fonde sur leur experience pour soutenir la prestation de services, le plaidoyer, la formation clinique et la recherche en sante genesique. Ces organisations ont accepte d'utiliser des directives communes, de definir conjointement les priorites et de partager les ressources, permettant ainsi de mener des operations plus harmonieuses et de reduire le nombre d'activites qui se chevauchent. Les progres futurs seront influences par les tendances dans ce domaine, notamment la priorite accrue accordee aux personnes deplacees a l'interieur de leur pays et qui vivent hors des camps, en plus des refugies des camps, la duree prolongee des urgences et le besoin croissant de donnees empiriques.

Resumen

El continuo descontento politico y civil en paises con pocos recursos recalca la necesidad continua de proporcionar servicios especializados en salud reproductiva para personas desplazadas. Las mujeres desplazadas en particular afrontan una alta tasa de mortalidad materna, necesidad insatisfecha de planificacion familiar, complicaciones despues del aborto inseguro y violencia basada en genero, asi como enfermedades de transmision sexual, incluido el VIH. Las organizaciones de socorro y desarrollo y organismos de la ONU han elaborado materiales tecnicos, realizado cambios positivos a las politicas, especificos a los ambitos de crisis, y estan trabajando para proporcionar mejores servicios de salud reproductiva. Sin embargo, aun existen importantes brechas. La colaboracion en el campo de la salud reproductiva en crisis es notable, ya que muchos organismos trabajan en una o mas redes. La Iniciativa RAISE de cinco anos reune importantes organismos de la ONU y ONG de los campos de socorro y desarrollo, y se basa en su experiencia para apoyar la prestacion de servicios de salud reproductiva, actividades de promocion y defensa, capacitacion clinica e investigacion. La buena disposicion para utilizar documentos de orientacion en comun, determinar prioridades conjuntamente y compartir recursos ha propiciado mejores actividades y menos traslapo que si cada organismo hubiera trabajado independientemente. Futuros avances serin influenciados por las tendencias en el campo, como un mayor enfoque en las personas desplazadas internamente, aquellas fuera de los campamentos y los refugiados en los campamentos, la prolongada naturaleza de las urgencias y la creciente necesidad de evidencia empirica.

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REFUGEES and those displaced through conflict and natural disaster hold no lesser claim to the fundamental right to health than those living in stable situations. The 1994 International Conference on Population and Development (ICPD) Programme of Action (1) specifically included displaced populations in its affirmation of the link between existing human fights treaty provisions and reproductive rights. Yet, the capacity of displaced people to exercise their rights is severely compromised. (2) It is essential, therefore, that national and international policy supports equitable systems which maximise accessibility for all sectors of the population to critical reproductive health services. (3)

The devastating effects of war on women, long recognised by those in the relief and development worlds, (4-6) are increasingly being documented and brought to the attention of a wider audience. (7-9) Still, while food aid, water and sanitation remain vital first responses in humanitarian crises, the role of reproductive health services as an additional priority service is increasingly being recognised.

The United Nations High Commissioner for Refugees (UNHCR) estimates that there are 32.9 million displaced people globally (10)--equivalent to one out of every 170 people in the world. Yet just a third of this number are officially recognised as refugees. Designated refugee status--and the protection it affords--does not apply equally to the internally displaced persons (IDPs), asylum seekers, returnees, stateless people and others of concern that constitute the remaining two thirds of the world's displaced. Like refugees, IDPs have been driven from their homes and prevented from returning due to protracted conflict, yet, unlike refugees, IDPs have not ventured outside the borders of their own country. The lack of refugee status may constrain the response of some aid agencies, while the capacity of the state to provide services to IDPs is typically impaired due to inherently weak systems, ongoing hostilities and the remote and underserved locations to which people have been driven.

This paper documents the development of this special focus within the fields of relief and development, explores the reproductive health needs of refugees, IDPs and those affected by conflict, and introduces the RAISE Initiative, a collaboration between Columbia University and Marie Stopes International, designed to promote reproductive health in crises through partnerships with UN, humanitarian and development organisations.

History and development of the field of reproductive health in crises

Focused attention to the reproductive health needs of those affected by conflict and natural disaster can be dated to the mid-1990s. (11) A 1993 Lancet editorial (12) denounced the absence of services for these populations. In 1994, the Women's Commission for Refugee Women and Children published the seminal report Refugee Women and Reproductive Health Care: Reassessing Priorities highlighting the lack of reproductive health services available to displaced women. (13) That same year, the ICPD (1) identified reproductive health as a basic human right and determined the reproductive rights of displaced women to be equal to those of women everywhere. The 1995 Fourth World Conference on Women in Beijing reiterated these rights. (14)

The movement to address displaced women's reproductive health needs gathered momentum in 1995 with the formation of two collaborative groups. The larger one, the Inter-Agency Working Group on Reproductive Health in Crises (IAWG), (*) brought together some 40 UN, governmental and non-governmental organisations, encompassing both humanitarian and development expertise, with the objective of increasing access to good quality reproductive health services for displaced people. In 1999, IAWG produced the first ever field manual, Reproductive Health in Refugee Situations: An Inter-Agency Field Manual, which has detailed chapters on: safe motherhood; sexual and gender-based violence; sexually transmitted diseases, including HIV and AIDS; and family planning. (15) A revised version of the manual, incorporating technical advances in reproductive health and guidance gleaned from field experience, is underway and will be published in 2009. The second group, the Reproductive Health Response in Conflict Consortium (RHRC), is a seven-member coalition which supports increased access to reproductive health care through collaborative advocacy, development of technical resources and field support. [dagger] It has been observed that collaboration across the field of reproductive health in crises has been especially long-lasting and productive. (11)

Key advances in the field include the development of the Minimum Initial Service Package (MISP), a set of priority activities to address reproductive health needs that was introduced in the IAWG Inter-Agency Field Manual. It is designed to be put in place in the first clays and weeks of an emergency, as a routine element of humanitarian response. The MISP requires on-the-ground staff to coordinate reproductive health response across responding agencies; prevent and manage gender-based violence through enhancing security and providing medical and psycho-social response; reduce HIV transmission by making condoms available and assuring universal precautions in clinical settings; prevent excess neonatal and maternal morbidity and mortality by making clean delivery kits available and by establishing a referral system to emergency obstetric care; and plan for comprehensive reproductive health services to start as soon as the emergency situation begins to stabilise. (16, 17) By clarifying the precise set of activities that must be carried out to respond to the emergency reproductive health needs of populations in crisis, the MISP can speed up agencies' actions on the ground.

Other markers of development of the field since the mid-1990s include the creation of a range of RH technical manuals and guidelines specific to crisis settings by individual agencies and groups of partners; (18-20) successful advocacy for policy change carried out in UN, donor and NGO fora; (2) professional conferences held in 2000 and 2003, sponsored by the RHRC Consortium, and a forthcoming conference in 2008 sponsored by the RAISE Initiative in collaboration with the RHRC Consortium, to promote knowledge-sharing; (21,22) research studies carried out; and journal articles published. Most importantly, humanitarian agencies, supported by dedicated funding and the newly available policy and technical guidance, began to shift policies and field procedures to deliver reproductive health services to people in conflict settings. (2)

A key event that has guided the field into its second decade is IAWG's global evaluation of reproductive health in crisis settings, begun in 2002 and published in 2004. (2) The evaluation, conducted by IAWG member agencies, was based on the framework for implementation outlined in the IAWG Field Manual. Its objectives were to assess the range and quality of services provided to refugees and IDPs and identify factors that helped or hindered care and lessons learned in the first decade of activity. It comprised six studies: a literature review; a global survey of reproductive health coverage for refugee and IDP populations in 33 countries based on agency self-reports; an assessment of availability and quality of reproductive heath care based on visits to three field sites (Uganda, Democratic Republic of Congo and Yemen}; a survey and on-site {in Chad} review of reproductive health response in crisis situations; a review of NGO policy and institutional change based on key informant interviews; and a review of global resource trends over the previous decade.

The results of the evaluation showed that reproductive health had progressed far in a decade but substantial gaps remained in services, institutional capacity, policy and funding. For example, refugees in stable camp settings were more likely to have access to reproductive health services than were IDPs, those not living in camps and those in new emergencies. All reproductive health services were not equally available: basic family planning and antenatal care were most common while emergency obstetric care, clinical family planning methods, care for survivors of gender-based violence and management of STIs were rarely offered. Services designed to reach adolescents were rarely available. The evaluation also identified the need to improve data collection and use and improve cross-agency collaboration. Finally, the evaluation endorsed effective advocacy for the inclusion of populations in crises in development policies and funding and the inclusion of comprehensive reproductive health in all humanitarian response.

The need for better coordination of humanitarian response has long been recognised. The Sphere Minimum Standards, (36) developed by NGOs following the response to the Rwandan genocide, was an effort to establish clear guidance for humanitarian responders in all sectors. The MISP, along with a set of reproductive health indicators, was included as a standard in the 2004 revision. Though adherence to Sphere standards is voluntary, most experienced humanitarian NGOs take its guidance very seriously. Consequently, the inclusion of a reproductive health standard was an important mark of progress for the field.

The UN's Humanitarian Response Review in 2005 prompted a further effort toward improving coordination through the development of the cluster approach, currently being piloted in seven countries. With each of the nine selected technical areas (including health, logistics, nutrition and protection} beaded by a technical "global cluster lead,' this approach aims to enhance coordination and collaboration among humanitarian actors and strengthen technical capacity and service delivery on the ground. One of the key roles of the WHO, the global lead for the health cluster, was to identify best practices from which standards and policies could be set at the local level.

Reproductive health, new to many actors involved in the cluster approach and the Basic Package of Health Services, (23) is a service at risk of being excluded as these new systems are implemented. Some reproductive health elements, such as post-abortion care and the full range of family planning methods, are particularly vulnerable.

Thus, in the almost 15 years since the reproductive health needs of those affected by conflict and natural disaster began to receive focused attention, substantial progress has been made in both policy and practice. Changes in the humanitarian environment have contributed to the advances, as well as the challenges of providing reproductive health services in crisis settings. An appreciation of these trends is critical if their potential impact on and contribution to the field is to be grasped.

Trends in the field

Work within complex emergencies, once chiefly focused on refugees in camp settings, has shifted in recent years to reflect the emergence of IDPs, very often in non-camp settings, as the predominant group. One such example is Colombia, where IDPs live in an isolated region and despite being citizens of the country, are unable to access health services (Box 1).
Box 1. Family planning in Colombia

The Colombian government, the UN and multiple NGOs
report that the number of Colombian IDPs is 1-3
million, making Colombia home to either the largest or
second largest population of IDPs in the world.

In Colombia, registration with the Sistema General de
Seguridad Social en Salud (General System of Health
and Social Security) is required to receive health care at
any public institution. However, only half of IDPs are
registered; the remainder lack access to crucial health
care, including family planning.

A large number of IDPs reside in the Pacific region, a
geographically isolated area where highways and
remote river routes used for shipping and transport are
controlled primarily by drug traffickers. This makes
travel difficult and dangerous.

The RAISE Initiative helps Profamilia, the leading NGO
provider of family planning services in Colombia, to
deliver services to marginalised communities in the
Pacific region. Mobile Profamilia brigades travel by
road and on foot, carrying supplies on their backs. Once
in the Pacific region, they work from improvised clinic
sites, offering family planning services as well as Pap
smears, antenatal care and general medical
consultations.


Concurrently, experience has highlighted the protracted nature of emergencies. UN agencies, humanitarian NGOs and local government authorities have adapted to this reality by, for example, collaborating to improve and maintain local health facilities rather than routinely establishing stand-alone NGO services. In addition, relief agencies are considering health services other than the immediate life-saving interventions they traditionally provide. (24) These conditions also lead development agencies to intervene, since crisis settings are similar to the under-resourced but stable settings to which they are accustomed. In many extended conflict and post-conflict settings, the distinction between "relief" and "development" is not clear cut.

As humanitarian agencies move into the provision of reproductive health services, their need for improved technical capacity is increasingly recognised. A number of humanitarian agencies now employ reproductive health specialists or partner with reproductive health agencies. Similarly, as development agencies initiate activities in areas newly emerging from conflict, they benefit from partnerships with humanitarian agencies accustomed to working in these fragile zones. The RAISE Initiative provides support for reproductive health activities to three such agencies working in Darfur (Box 2).
Box 2. Comprehensive reproductive health
care in Darfur

Darfur remains one of the worst humanitarian crises
in the world today. There are currently 1.8 million
displaced people in the region. Humanitarian
agencies are working hard to address the needs of
the population, but reproductive health care is
rarely sufficient.

In particular, emergency obstetric care, including post-abortion
care, is generally not available when women
and girls suffer serious complications from pregnancy,
childbirth or unsafe abortion. For these problems and
others, there are long delays in seeking treatment, and
what little care can be provided is far from adequate.
Women reach hospitals with grim prognoses, further
complicated by having to travel long distances and
lack of appropriate care during transfer and upon
arrival at hospitals. (25)

The RAISE Initiative collaborates with the American
Refugee Committee, International Rescue Committee
and Save the Children to support their existing health
care programmes by providing comprehensive
reproductive health services to IDPs in all three states
of Darfur. RAISE Initiative partners equip and renovate
health facilities, provide supplies, and recruit and build
the capacity of health staff to improve reproductive
health throughout this region.


Organisations serving conflict-affected populations have increasingly recognised the need for empirical evidence to assess the effectiveness of programmes and interventions (26, 27) and for prioritising public health policy and programmes. (28) Recent pressures exerted on agencies from both donors and beneficiaries have served to increase the value placed upon the development of monitoring and evaluation systems. Although their primary function is to inform programme planning, evidence derived from good quality data systems provides a useful tool for feedback to governments, donors and other policymakers.

Family planning, maternal health and STI/ HIV-related needs of refugees and IDPs

Evidence in respect of fertility desires amongst forced migrants has been equivocal, with both an inclination to replace lost children and a reluctance to assume the burden of parenting within conditions of such extreme uncertainty being reported. (29, 30) While the reproductive choices of refugees and displaced persons must be respected, as in any other population, considerable unmet need for family planning is likely. In IDP camps in northern Uganda, for example, unmet need was found to be 58%, compared to the national average of 40.6%. (31) Women using short and medium term contraceptive methods at the time of displacement may wish to continue. Without accessible family planning services, provided in accordance with the state's ethical mandate, no possibility exists for them to do so, nor does any alternate solution aside from abstinence or unsafe abortion present itself. An evaluation of services in conflict-affected sites undertaken in 2004 found that while 90% of sites had at least one method available, only 50% of sites were able to offer IUDs and 36% sterilisation, while implants were not mentioned at all. (2) Although choice of method is an essential component of good quality family planning programmes, (32) women's choices at these sites were limited to a few hormonal methods.

Maternal mortality is unacceptably high in developing countries, and countries in conflict and post-conflict have among the highest levels of maternal mortality in the world. Women in Sierra Leone, a country at war from 1991-2002, face a 1:6 lifetime risk of dying from complications of pregnancy and delivery; for those in Uganda and Democratic Republic of Congo, the risk is 1:13, while for their counterparts in Sweden it is 1:29,800. (33) Bartlett et al estimated the maternal mortality ratio in Afghanistan after two decades of war at 1,600 deaths per 100,000 live births, ranging from 400 in Kabul to 6,500 in rural Badakshan. (34)

A complex humanitarian emergency imposed on an already weak health system compounds the risk of maternal death. Women's lives continue during displacement. Neither the risk of becoming pregnant nor that of subsequent complications is reduced as a function of the difficult circumstances under which they are living. In the absence of appropriate abortion services, women resort to unsafe means. (5) Provision of emergency obstetric care requires skilled providers with direct access to functioning health facilities where relatively sophisticated procedures can be performed. If the right to health is to be operationalised, governments, assisted by humanitarian agencies where necessary, must establish emergency obstetric services, including post-abortion care, within reach of camps and of the sprawling settlement areas surrounding them, and include transportation to referral sites.

Debate amongst researchers exists as to whether transitory living conditions exacerbate or ameliorate the spread of HIV infection. Traditional wisdom has suggested that the conditions of deprivation experienced by displaced populations including food insecurity, lack of water and sanitation and the consequent debility, together with sexual violence, provide fertile ground for the spread of infectious diseases, including HIV/AIDS. (35) Prevalence estimates from Northern Uganda, where civil unrest has persisted for more than ten years, lend support to this notion. (36) A recent meta-analysis proved equivocal. (37) This analysis suggested that the background HIV prevalence of both the home and refuge areas interact with the proximity of the settlements to urban areas and a host of behavioural variables to determine the direction of HIV incidence rates amongst the displaced. Inter-Agency Standing Committee Task Force on HIV/AIDS in Emergency Settings guidelines (38) reiterate the need to incorporate HIV prevention into all emergency responses. At present, prevention of HIV and care and treatment of people with AIDS remain vital services for conflict-affected populations, many of whom are found in sub-Saharan Africa, the epicentre of the AIDS pandemic. Little data exist on the prevalence of STIs in conflict settings. As with HIV, it is likely that interacting factors, including underlying prevalence, movement and behaviour, affect STI prevalence among displaced populations. Conflict has been cited as a reason for lack of success in STI control efforts. (39)

Gender-based violence

Deliberate and widespread use of rape is known to be a powerful means through which to undermine and demoralise populations in times of conflict. (40) This tactic has been ruthlessly employed in Rwanda, Democratic Republic of Congo and Darfur, with the majority of cases going unreported. (41) Women, the primary targets of this violence, are left with long-term psychological and physical injuries. The stress of desperate living conditions is also associated with the perpetration of sexual violence against immediate family members. In Uganda, (42) Thailand (43) and Colombia (44)--all countries currently experiencing crises or hosting populations fleeing conflict--the proportion of women who have experienced intimate partner violence ranges from 23% to 44%. While it is axiomatic that prevention should be the goal, interim solutions in the form of improved and effective treatment options accessible to survivors of rape and other forms of gender-based violence are needed. Furthermore, systems for reporting and monitoring these events, and advocating against apparently increasing tolerance of high levels of abuse in humanitarian settings, need to be instituted or improved and sustained. (28,45)

Special needs of adolescents

Loss of social structures, changes in power relationships, idleness, substance abuse and separation of family units during emergencies lead to new vulnerabilities and increased risks for adolescents. (6, 46) Humanitarian emergencies exact a great toll on teens in their transition to adulthood. Deprived of traditional social structures, adolescents are particularly vulnerable to sexual abuse and exploitation. For example, a survey conducted in Sierra Leone in 1999 found that 37% of prostitutes were under the age of 15, 80% of whom had been displaced by war. (47) Unprotected sex, early pregnancy, spread of STIs and exploitation by older partners increase in such environments. Additionally, the armed conflict itself uniquely affects young people, both male and female. In El Salvador, Ethiopia and Uganda, one-third of all child-soldiers are girls. (48)

Roughly one-third of all those displaced by conflict are adolescents. The increased risk experienced by this already vulnerable group is further exacerbated by their presence in a setting with little or no access to health systems, information, counselling, guidance or protection. (46) WHO and IAWG have recognised the importance of addressing the needs of this sub-group through the development of a dedicated chapter within the Inter-Agency Field Manual. is The specific vulnerabilities of adolescents highlight the importance of their involvement in the planning and design of projects intended to serve them. Interventions deemed most effective have targeted information-sharing, empowerment and accessibility of adolescent-friendly services. (6)

Remaining gaps

It is clear from the available data and from the experiences of those working in the field that people affected by conflict and natural disaster need and deserve good sexual and reproductive health care. A minimum package of services must be available from the start of an emergency, and be expanded as the situation stabilises to encompass comprehensive care.

Findings of the IAWG evaluation identified serious gaps in reproductive health service provision and funding, and missed opportunities for collaboration, (2) such as, for example, that advances in service coverage have been largely concentrated in stable, refugee camp settings. It is worrisome that services available to IDPs are limited, given the increasing prominence of this group of conflict-affected people.

The evaluation also showed that all the components of reproductive health were not necessarily uniformly provided for, where available at all. The most established services were family planning (primarily temporary and barrier contraceptive methods), safe motherhood (largely antenatal care) and condom distribution, the most familiar and first adopted services. The less familiar services--response to gender-based violence, STI/HIV/AIDS services other than condom distribution, emergency obstetric care and youth-friendly services were not routinely available in most sites. (2) In the last several years, however, anecdotal information suggests that these services, especially response to gender-based violence and treatment for STIs, have expanded as more agencies in more sites recognise the needs and as donors support their efforts.

[ILLUSTRATION OMITTED]

A review of funding practices conducted as part of the IAWG evaluation revealed that after an initial increase in funding for women's health following ICPD, a steady downward trend was evident from 2000 to 2004. (2) This mirrors the trend in overall donor assistance for reproductive health. (49) Although government donors remain the major funders of emergency work, the role of private donors has assumed increasing significance as agencies have sought supplementary means through which to sustain vital programmes.

Linkages between the reproductive health community and the humanitarian sector have been limited. For example, none of the articles in a special series on reproductive health and another on maternal mortality in the Lancet in 2006 referred to displaced or conflict-affected women. (50)

There is an urgent need for the mainstreaming of reproductive health within relief organisations, both at headquarters and in field operations. There is an equally urgent need for reproductive health organisations to recognise the reproductive health needs of those affected by conflict and natural disaster, and mainstream this response into their institutional and field operations. Whilst periods of protracted conflict have promoted greater collaboration between relief agencies and host governments, most reproductive health agencies have yet to engage fully in emergency settings. The integration of their technical expertise would strengthen the relief response considerably.

The RAISE Initiative

The Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative is a major new programme designed to catalyse change in the ways in which comprehensive reproductive health is addressed in field services, relief organisations and global decision-making. A joint initiative of the Columbia University Mailman School of Public Health and Marie Stopes International, its aim is to ensure that good quality comprehensive reproductive health services are routinely provided to those in emergency situations. Focusing on settings with particularly high IDP populations, RAISE supports projects in inter alia Chad, Colombia, Democratic Republic of Congo, Sudan and Northern Uganda. RAISE brings together major NGOs and UN agencies from the fields of relief and development, building on their long-term experience. Partners include the American Refugee Committee, CARE, the International Rescue Committee, JSI Research and Training Institute, Marie Stopes International partners, Profamilia Colombia, Save the Children, UNFPA and the Women's Commission for Refugee Women and Children.

Unlike many relief programmes, RAISE is a long-term venture begun in raid-2006 and continuing until 2011. The programme integrates financial and technical assistance, advocacy, clinical training, and research. The aim is to strengthen institutional commitment to comprehensive reproductive health service delivery and expand good quality services in crisis settings, and strengthen the policy and funding environment for the provision of these services in refugee and IDP situations, focusing on the following areas:

* basic and comprehensive emergency obstetric care, including post-abortion care,

* all family planning methods and emergency contraception,

* sexually transmitted infection prevention and treatment,

* HIV prevention, voluntary counselling and testing, prevention of mother-to-child transmission and referral, and

* medical response and referral for gender-based violence.

The length of programming enables partner agencies to develop expertise and to provide comprehensive services, rather than the more limited range that can reasonably fit into the familiar 6-12 month projects, to set longer-term objectives and monitor results, and to strengthen linkages between relief and development partners.

For example, in northern Uganda, where armed conflict has continued for over 20 years, there are as many as 1.2 million IDPs. (51) Access to medical services is limited, meaning that women have little access to family planning, and post-abortion care has not been addressed by humanitarian agencies as part of basic health care needs, despite its potential to save lives. The RAISE Initiative works with Marie Stopes Uganda in four districts of northern Uganda, to provide post-abortion care for displaced women, with plans to expand outreach services in cooperation with other humanitarian aid providers in the coming years.

To ensure high quality service delivery by its partner agencies, RAISE provides clinical training and follow-up, both in the field, at MSI's comprehensive reproductive health centre in Nairobi and at the Centre for Research and Training for Quality of Reproductive Health Care at Souro Sanou University Hospital, Bobo Dioulasso. Training of trainers and competency-based trainings give health teams from NGOs and ministries of health the opportunity to update and develop their clinical skills in high quality comprehensive reproductive health care settings. Participants return to their health facilities, whether in refugee camps or in the community, not only equipped with the skills needed to provide quality services, but with support and supervision to ensure their improved skills are utilised and maintained.

In addition, RAISE is working with leading international humanitarian agencies to increase their capacity to provide reproductive health services. Activities to date have included input to policy and clinical training for headquarters and field-based staff.

The dearth of good quality data from conflict settings has long been recognised as a limitation precluding accurate portrayal of the level of need and the consequent procurement of adequate funding for services. Routine data collection has been found to be very limited in many settings with little or no utilisation of such data, even when recorded. Improved monitoring and evaluation systems are another means by which to improve services. Although data generated by large, methodologically sophisticated studies are valuable, it is the ongoing collection and utilisation of routine data that is essential--for programme development, documentation of progress and advocacy.

RAISE's objectives are supported and magnified through the sharing of knowledge among partner organisations and beyond. A wide range of knowledge-sharing mechanisms is used to reach practitioners, managers and decision-makers at all levels. In June 2008, RAISE, together with the Reproductive Health Response in Conflict Consortium, will host the Reproductive Health in Emergencies Conference (<www.raiseinitiative.org/conference>) through which renewed attention to reproductive health in emergencies will be directed. The conference will provide an opportunity to showcase best practices, present technical updates, share programme experience and evaluation, and appraise the current policy environment. Above all, the conference will identify opportunities for progress, inspire action and present concrete solutions for both policymakers and health providers working in this area.

Since its inception, RAISE has already observed an increase in the reproductive health components of emergency responses and witnessed growth in the range and extent of field services utilised within out partner field sites. RAISE's global advocacy efforts are a critical corollary to this, focusing as they do on the policy and funding changes needed to secure reproductive health services for displaced communities through relief and development assistance.

Discussion and conclusion

Action to address the reproductive health and rights of those affected by conflict and natural disasters was spurred in the 1990s by the inclusive nature of the Programme of Action of the Cairo International Conference on Population and Development and by the willingness of those concerned to work collaboratively. Activists' resolve to articulate clear technical guidelines, use evidence from the field, advocate for action by the development and humanitarian fields and by donors and policymakers and, ultimately, provide reproductive health services to these populations formed a solid foundation.

The collaboration within the field of reproductive health in crises is notable, with many agencies active in the field working in one or more networks. IAWG provides a ready mechanism of communication and joint action. Indeed, one reason the findings of the global evaluation were readily acted upon was that the evaluation was undertaken by them with the active participation of many member agencies. The readiness across agencies to use common documents, such as the IAWG Inter-Agency Field Manual, to be guided by jointly developed priorities and to share resources has led to greater efficiency, smoother operations and less overlap than would likely be the case were each agency to operate independently.

The field has adapted well to global events and trends. When findings from the global evaluation showed that camp-based refugees were relatively well-covered for reproductive health services, programmatic attention was shifted to include IDPs and those not living in camps. When the same evaluation indicated that availability of comprehensive reproductive health services was the exception, agencies worked to expand those that were lacking. While comprehensive reproductive health care is by no means the norm in refugee or IDP settings, substantial progress towards this goal has been made since the raid-1990s.

The current climate of continued political and civil unrest in low-resource countries underscores the ongoing need for specialised services for displaced people. Thanks to the vision of ICPD, the reproductive rights of conflict-affected persons are not negotiable. For refugees and internally displaced women, men and young people to truly be accorded those rights, however, governments, donors, academic institutions and relief and development agencies, including the UN system and NGOs, need to increase their commitment at grassroots, national and international levels and to ensure the delivery of comprehensive reproductive health services at the standards set by LIN Inter-Agency Standing Committees and entities such as Sphere and the Inter-Agency Working Group on Reproductive Health in Crises.

References

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* This group was originally named the Inter-Agency Working Group on Reproductive Health in Refugee Situations.

([dagger]) The members of the RHRC Consortium are the American Refugee Committee, CARE, Columbia University Mailman School of Public Health, International Rescue Committee, JSI Research and Training Institute, Marie Stopes International and the Women's Commission for Refugee Women and Children.

Judy Austin, (a) Samantha Guy, (b) Louise Lee-Jones, (c) Therese McGinn, (d) Jennifer Schlecht (e)

(a) Head: Research, Monitoring and Evaluation, RAISE Initiative, Mailman School of Public Health, Columbia University, New York NY, USA. E-mail: ja2026@columbia.edu

(b) Deputy Director, RAISE Initiative, and Senior Advisor on Reproductive Health in Refugee Settings, Marie Stopes International, London, UK

(c) Programme Manager, RAISE Initiative, and Project Manager, Marie Stopes International, London, UK

(d) Director, RAISE Initiative, and Associate Professor of Population and Family Health, Mailman School of Public Health, Columbia University, New York NY, USA

(e) Research, Monitoring and Evaluation Officer, RAISE Initiative, Mailman School of Public Health, Columbia University, New York NY, USA

Distinguished Professor of Political Science, Political Science Department, Hunter College Graduate Center, City University of New York, New York NY, USA. E-mail: rpetches@igc.org

* The ICPD Programme of Action adopted as an objective, in paragraph 9.20(b): "To put an end to all forms of forced migration."
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Author:Austin, Judy; Guy, Samantha; Lee-Jones, Louise; McGinn, Therese; Schlecht, Jennifer
Publication:Reproductive Health Matters
Date:May 1, 2008
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