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Summary Report: Second Meeting of the Inter-
Agency Working Group on Reproductive Health
In Refugee Situations

Released by the Bureau of Population, Refugees, and Migration, July 1997

The Inter-Agency Working Group on Reproductive Health in Refugee Situations (IAWG), chaired by the UN High Commissioner for Refugees (UNHCR), met for the second time on June 23-24, 1997, in Geneva. The purpose of the meeting was to discuss progress in the reproductive health for refugees (RHR) since the last meeting, experience with the Minimum Initial Service Package (MISP), contents of various reproductive health supplies kits, reproductive health indicators, prioritization of the RHR research agenda, field testing of the UNHCR Field Manual, and next steps. As a result of the meeting, the IAWG made a recommendation to the World Health Organization (WHO), supporting the inclusion of reproductive health supplies, including hormonal contraceptives and swaddling cloth for newborns, in the supplementary New Emergency Health Kit.

A. Background and Progress

On June 23-24, 1997, the UNHCR-chaired IAWG on Reproductive Health in Refugee Situations met for the second time. The IAWG, an initiative of the June 1995 Symposium on Reproductive Health for Refugees, was created to bring governments and humanitarian aid agencies together to support and promote the integration of reproductive health into overall refugee assistance programs in a coordinated and cooperative manner--and to assist in the implementation of the draft Inter-Agency Field Manual for Reproductive Health in Refugee Situations.

Membership in the IAWG has grown by three organizations (10%) since the first meeting in November 1996. Each of the participating groups gave a brief report on its activities since the first meeting of the IAWG. There are now three subgroups of the IAWG: reproductive health indicators, research, and quality of care.

B. Experience With the Minimum Initial Service Package (MISP)

The Minimum Initial Service Package (MISP), detailed in the Field Manual, is the name given by the IAWG to the mix of reproductive health goods, services, and activities necessary during the initial phases of a refugee situation. A MISP is not a physical package but an approach to reproductive health care in an emergency and beyond. As a concept, the MISP goes well beyond the provision of a "package" of goods. It encompasses, in addition to certain recommended supplies, necessary data collection efforts; essential reproductive health services, such as emergency contraception and assurance of a safe blood supply; and the planning process for later phases of the emergency. Within the MISP concept, there are specific supplies necessary to enable the delivery of basic reproductive health services. These supplies include materials necessary for clean births (clean delivery kits), condoms and informational materials for the prevention of transmission of HIV/AIDS and other sexually transmitted infections, and a limited range of contraceptives for use in emergency contraception in cases of rape and sexual violence and serving continuing family planning users.

The concept of the MISP has been very useful in both establishing the idea that basic reproductive health is important from the beginning of an emergency and providing some specificity as to what is needed. The choice of name, however--specifically, the word "package"--has led to some confusion between the MISP, the WHO New Emergency Health Kit, and the proposed UNFPA Reproductive Health Kits.

Milicent Obaso, of the International Federation of Red Cross and Red Crescent Societies (IFRC), presented findings from her work implementing the MISP for the first time. Her initial needs assessment uncovered the lack of provision of a broad range of reproductive health services. Maternal and child health and family planning tended to be the only services provided, while services to address HIV/STD, sexual and gender violence, post-abortion care, and adolescent needs were extremely rare.

Obaso eventually trained 40 people as trainers: 17 in responding to sexual and gender violence--9 in Tanzania and 8 in Uganda--and 23 in adolescent and basic reproductive health. She also distributed 15 reproductive health supply kits: clean birth kits, male kits, female kits, and emergency contraception kits.

Constraints she faced were a delay in starting the implementation, the mobility of the refugees in the great lakes, the need to educate the relief division within IFRC about the issue, the location of the project base, the late arrival of the supply kits, and a lack of capacity among NGO staff in the field requiring a crash program in training of trainers.

Obaso learned that the concept of reproductive health is still relatively new, and there is still a need for advocacy; that gender and sexual violence is rarely discussed or reported, again requiring a need for more advocacy and advance training; that various supply kits should be in place ahead of time and NGO staff trained in their use; that better collaboration is required among the NGOs; and for those NGOs lacking the capacity at the camp level to provide services, a system of referral to the local hospital or clinics, in addition to strengthening the relationship with the host government, is necessary.

Obaso's first test case of implementing the MISP concept has paved the way for the provision of reproductive health services in all other phases and quite possibly positioned the MISP for immediate application in the next emergency.

Decision: The group reconfirmed its support for the MISP concept; i.e., highlighting the importance of reproductive health in the early phases of an emergency and defining specific reproductive health services, goods, and activities as essential.

C. Contents of Various Reproductive Health Supplies Kits

Meeting participants held specific discussions regarding the contents of two forms of supply kit to be available for refugee situations: the WHO revised New Emergency Health Kit (NEHK) and the refugee health kits that will be available from UNFPA. The NEHK contains the basic supplies for handling health needs in emergency situations. It will replace WHO's "Health Center in a Box" kit that is designed to be on site immediately in an emergency. Its contents list is being revised to include supplies for reproductive health. In its current draft, the proposed supply list did not include hormonal contraceptives. The group strongly recommended that this be changed and that the kit include both a supply of oral contraceptives (OCs) and injectable contraceptives.

To complement the NEHK, UNFPA is assembling supply kits in 17 specific reproductive health areas. These kits range from supplies of condoms and informational materials to surgical equipment for cesarean sections. The group supported both the concept and the contents of these kits as a complement to the NEHK but urged that they be considered neither as a substitute for the NEHK nor as substitute for establishing a resupply pipeline for ongoing operations.

Decision: The IAWG endorsed the addition of reproductive health supplies to the NEHK and strongly recommended that a supply of hormonal contraceptives (both OCs and injectables) and swaddling cloth for newborns be included.

D. Reproductive Health Indicators (RH)

The indicators working group reported on their efforts to refine and specify the list of basic reproductive health measures. The group held a lengthy discussion about the specific indicators to be used and monitored during the emergency phase. Following the discussion, the working group was directed to finalize the indicators list and to be specific about the collection, manipulation, and use of data and indicators in the early phases of emergencies.

Decision: The IAWG directed the indicators working group to continue to develop a set of recommendations, with assistance from WHO.

E. Prioritization of the RHR Research Agenda

The working group on research reported on its activities to organize the research agenda previously proposed by the IAWG. It then led the group through an exercise to select and prioritize 12 specific research topics. At the conclusion of this exercise, the full group had provided its input to the research working group, and the research working group was going to process this input and report back.

Decision: The IAWG directed the research working group to finalize the prioritization of research topics and begin the process of seeking research organizations to undertake the highest priority activities.

F. Field Testing of the UNHCR Field Manual

The UNHCR Field Manual on Reproductive Health in Refugee Situations was developed in 1996 through a collaborative effort by 50 UN and NGO agencies. It has been produced in English (more than 10,000 copies), French (2,000 copies) and Russian (200 copies). It has been distributed to more than 1,000 agencies in 60 countries.

The process of revising the Field Manual involves four activities:

First, in 18 countries, teams have been formed to field test the manual;
Second, all agencies whose names appear on the manual have been requested to review and suggest any changes;
Third, WHO has been requested to provide technical review and update; and
Fourth, other agencies, which are active in the reproductive health for refugees area, have been asked to review the manual and provide comments.

All comments on the manual are expected by September 1. The manual will be revised and redrafted by mid-October. One month after the redrafted manual is issued, the IAWG will meet to finalize any comments. The manual will then be reprinted for broad distribution in early 1998.

Decision: The IAWG reconfirmed the importance of finalizing the field testing of the Field Manual and agreed to submit comments by September 1.

G. Additional Items (Quality of Care and Barriers to Service)

Considerable discussion occurred during the meeting on quality of care. Some members of the group expressed concern that necessary quality of reproductive health services might be compromised in some circumstances in the rush to provide services during the hectic initial phases of an emergency. (This is a constant threat to any aspect of health care in an emergency. An appropriate response requires the simplest but most effective possible program design, taking into account the likely constraints.) Coincident with that discussion, other members expressed concern that efforts also need to be made to ensure that inappropriate barriers to services be minimized. Following these discussions, a working group was formed with the objective of continuing the exploration of quality of care issues. Hopefully, this group will develop recommendations to address appropriate quality standards--from both the minimum standards and removal of barriers perspectives--that can be integrated into the revision of the Field Manual. The working group on quality of care will meet the first week of September in London.

H. Next Steps

The IAWG decided to meet again approximately one month after the revised Field Manual was made available for final comment. This is currently anticipated to be in early December.

I. IAWG Members in Attendence
CARE International
Centers for Disease Control/Division of Reproductive Health
Centers for Disease Control/International Emergency and Refugee Health Program CRED-Universite Catholique/Belgium
Columbia University School of Public Health
Family Health International
International Center for Migration and Health
International Federation of Red Cross and Red Crescent Societies
International Organization of Migration
International Rescue Committee
IPAS
John Snow, Inc.
London School of Hygiene and Tropical Medicine
Marie Stopes International
Medicins Sans Frontieres/Switzerland
Oxfam
Save The Children/UK
UK Department for International Development
UNFPA/Geneva
UNFPA/New York
UNHCR/PTSS
UNICEF
U.S. Department of State/Bureau of Population, Refugees, and Migration
USAID/Population, Health, and Nutrition Center
World Health Organization
The Women's Commission for Refugee Women and Children.

The American Refugee Committee, the European Community Humanitarian Office, the International Committee of the Red Cross, the International Planned Parenthood Federation, Medicins Sans Frontieres International, USAID/Office of Foreign Disaster Assistance, and UNAIDS also are IAWG members but were unable to attend the meeting.

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