2. CARE’s Nexus Approach to SRHR in Emergencies

CARE supports access to SRHR services in humanitarian settings. CARE invests in acute and fragile contexts using a nexus approach to ensure agility to respond to emergencies while building back and strengthening the resilience of the health system.

Given the cyclical nature of emergencies and growing number of countries in fragile contexts, CARE works to 1) enhance preparedness efforts on SRHR through capacity building of government, local partners and other humanitarian actors, influencing policy on preparedness for SRHR in emergencies and strengthening coordination mechanisms across actors 2) enable agile, rights-based, people-centered, gender-sensitive emergency response efforts guided by the Minimum Initial Service Package for SRH in crisis-settings 3) strengthen government health systems that have been weakened by protracted or chronic crisis to deliver comprehensive SRHR services in fragile contexts with a focus on unlocking access to the most stigmatized SRH services and 4) cross-cutting approaches to support localization and gender and inclusive programming that are responsive to the needs and capacities of marginalization groups such as adolescents across all phases of a crisis.  These core elements of CARE’s SRHR in fragile contexts approach are aligned with CARE’s humanitarian directions emphasizing gender and localization across the nexus.

SRHR must remain a priority in all emergencies, including in epidemics. For SRHR programming in the context of COVID-19, see CARE’s guidance on Health/SRHR, and programmatic guidance from IAWG on COVID19 and a tool for MISP implementation in the COVID19 context.

1) Emergency Preparedness and Planning for SRHRiE

Sexual Reproductive Health and Rights in Emergencies (SRHRiE) is a core emergency sector for CARE and it is crucial that it is integrated into Emergency Preparedness Plans (EPP). Country offices need to ensure that an SRHR focused analysis and programmatic response is integrated into the preparedness planning to meet the immediate needs of crisis-affected women and girls. SRHR is an essential component of basic health service provision in crisis and during an emergency, it is one of the most critical issues for the population’s survival and well-being and must be an integral component of emergency planning.

Minimum preparedness actions on SRHRiE:

  • Ensure regular contact between CO and Emergency SRHRiE Global Team/Sector lead (at least annual) ​
  • Collaborate with UNFPA through participation in SRH sub-working group (or health cluster) and efforts to operationalize global MOU​
  • Identify an SRHR focal point on CARE Emergency Response Team
  • Ensure suppliers/vendors of SRH items are on the approved vendor list​
  • Capacity building of team on MISP and CARE SRHRiE Minimum Commitments to gender and diversity ​
  • Map out referral pathways, health facilities and human resource capacities ​
  • Ensure SRHR in standard rapid assessment tools​

This PowerPoint on Emergency Preparedness Planning for SRHR (Annex 26.5.20)  provides an overview of key considerations when planning for an SRH response.

The CARE SRHR in Emergencies (SRHRiE) emergency preparedness planning matrix (Annex 25.5.19) is to be used by country offices to ensure that an SRH focused analysis and programmatic response is integrated into the preparedness planning.

2) Minimum Initial Service Package (MISP) for SRH in Crisis Settings

The MISP is a coordinated set of life-saving priority SRH activities and services to be implemented at the onset of every emergency response. Ideally implementation should take place within 48 hours. The goal of the MISP is to prevent SRH-related morbidity and mortality while protecting the right of the affected community to life with dignity. The MISP can be implemented without an in-depth SRH needs assessment as there is documented evidence that it saves lives.  CARE’s “Demystifying the MISP” (Annex 26.5.21) tool breaks down each of the MISP’s 6 objectives into concrete activities that CARE, the community, and the health facility should implement.

Key Objectives of the MISP include:

  1. Ensure the health sector/cluster identifies an organization to lead implementation of the MISP
  2. Prevent sexual violence and respond to the needs of survivors
  3. Prevent the transmission of and reduce morbidity and mortality due to HIV and other sexually transmitted infections (STIs)
  4. Prevent excess maternal and newborn morbidity and mortality
  5. Prevent unintended pregnancies
  6. Plan for comprehensive RH services, integrated into primary health care as soon as possible. Work with the health sector/cluster partners to address the six health system building blocks

Other priority: It is also important to ensure that safe abortion care is available, to the full extent of the law, in health centers and hospital facilities.

Why the MISP?

During emergencies, sexual and reproductive health needs not only continue, but also increase. Thirty-five million of the 134 million people in need of humanitarian assistance are women and girls of reproductive age. Of the preventable maternal deaths that occur globally, 60% occur in humanitarian emergencies. In the middle of an urgent crisis situation, women will give birth, nurse their newborns and require medical attention. Despite (or perhaps because of) the sudden loss of home, community, and livelihood options that accompany disasters, people will engage in sexual activities, many with consent but some without consent and as acts of violence. Many people will be coerced into sex against their will so as to survive. Many will be survivors of rape. The conditions that define a complex emergency (conflict, social instability, poverty and powerlessness) favor the rapid spread of HIV/AIDS and other STIs and put women and adolescent girls in vulnerable situations.

3) Transition to comprehensive SRHR programming

Beyond the first 3-6 months of an emergency, it is important to transition to comprehensive SRHR programming guided by the  Inter Agency Field Manual on Reproductive Health in Crisis (IAFM) which is the authoritative resource on the topic and includes details information on the MISP.

Priorities could include:

    • Broadening and strengthening of MISP for SRH services
    • Inclusion of SRH services that fall outside of the MISP
  • Services, like MISP services, must be accessible for all affected populations
  • Requires a multi-sectoral (other health and social services), integrated approach
  • Services are essential SRH services that must meet public health and human rights standards, including the ‘Availability, Accessibility, Acceptability, and Quality’ framework of the right to health

Comprehensive SRH services should include:

  • Accurate information and counselling on sexual and reproductive health, including evidence-based, comprehensive sexuality education;
  • Information, counselling, and care related to sexual function and satisfaction;
  • Prevention, detection, and management of sexual and gender-based violence and coercion;
  • A choice of safe and effective contraceptive methods;
  • Safe and effective antenatal, childbirth, and postnatal care;
  • Safe and effective abortion services and care, to the full extent of the law;
  • Prevention, management, and treatment of infertility;
  • Prevention, detection, and treatment of sexually transmitted infections, including HIV, and of reproductive tract infections; and
  • Prevention, detection, and treatment of reproductive cancers.

Source:  Lancet, May 2018 Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher– Lancet Commission

Start planning for the integration of comprehensive SRH activities into primary health care at the onset of the humanitarian response in line with the health systems building blocks: service delivery, health workforce, health information system, medical commodities, health financing, governance and leadership. When planning for the delivery of comprehensive SRH, the clinical services put in place as part of the MISP should be sustained, improved in quality, and expanded upon with other comprehensive SRH services and programming throughout protracted crises, recovery, and reconstruction. After the situation stabilizes and while preparing for comprehensive SRH services, plan to obtain input from the community on the initial response in order to identify gaps, successes, and avenues for improvement.

See a programmatic example from CARE’s programming in Cox’s Bazaar.

4) Cross-Cutting Technical Approaches:

 Meeting the unique needs and leveraging the capacities of adolescents

Even in normal situations, adolescence is a period of transition between childhood and adulthood. Adolescents rely on their support networks of family, friends, and their community; however, in emergencies those networks are disrupted. They are often separated from their parents and are exposed to additional risks. While adolescents face unique risks, they also have additional capacities to support humanitarian response, and it’s important to engage them across the program cycle.

The IAWG Adolescent Sexual and Reproductive Health Toolkit for Humanitarian Settings provides additional resources and guidance for tailoring humanitarian response to the needs of adolescents.  One of CARE’s flagship projects for Adolescent SRH in Fragile Contexts is the Adolescent Mothers’ Against on Odds (AMAL) Approach. For additional information, see the toolkit and learnings.

Gender and Inclusion as a core component of SRHRiE

Irrespective of the phase of the humanitarian program cycle, CARE seeks to ensure SRHRiE programming builds on and integrates Gender in Emergencies key approaches including Rapid Gender Analysis, GBViE integration, Women Lead in Emergencies (see Gender in Emergencies page ) as well as the SRHRiE Minimum Commitments for Gender and inclusion (see below) while seeking to leverage the capacities of affected women, girls and other community members to build resilient health systems.

The SRHRiE Minimum Commitments for Gender and Inclusion is a tool intended to make gender sensitive and inclusive SRHRiE programming tangible, simple and practical. The intended users of these commitments are the sexual and reproductive health and rights (SRHR) professionals working in emergency settings, in countries recovering from crisis and in chronically fragile settings. The commitments are practical, realistic and focus on improving the way the sector teams operate rather than on drastically reorienting programmes, and thus commitments reflect key priority issues in a specific sector. They are not about stating again what is already known by the sector actors or already covered in existing guidance (such as, for instance, the importance of targeting women of reproductive age). They are about calling staff’s attention on important issues that may be overlooked, placing the focus on the very groups we tend to miss and on the good programming practices we fail to implement. As the commitments are meant to be used globally, they have been developed to be relevant in most contexts. The Minimum Commitments are based on a project team’s utilization of the self-assessment tool to reflect upon and encourage dialogue to inform action to contribute to more gender sensitive and inclusive programming

The minimum commitments are a tool meant to make gender sensitive and inclusive SRHRiE programming tangible, simple and practical. The intended users of these commitments are the sexual and reproductive health and rights (SRHR) professionals working in emergency settings, in countries recovering from crisis and in chronically fragile settings. The commitments are practical, realistic and focus on improving the way the sector teams operate rather than on drastically reorienting programmes, and thus commitments reflect key priority issues in a specific sector. They are not about stating again what is already known by the sector actors or already covered in existing guidance (such as, for instance, the importance of targeting women of reproductive age). They are about calling staff’s attention on important issues that may be overlooked, placing the focus on the very groups we tend to miss and on the good programming practices we fail to implement. As the commitments are meant to be used globally, they have been developed to be relevant in most contexts. The Minimum Commitments are based on a project team’s utilization of the self-assessment tool to reflect upon and encourage dialogue to inform action to contribute to more gender sensitive and inclusive programming

The following minimum commitments aim to develop practical approaches and actions to address the issues identified:

  • Assessment: Analyze how power dynamics within the home and the community affect girls’ and women’s access to life-saving sexual and reproductive health services to inform the targeting and the design of your support
  • Design: Develop your programmes for and with adolescent girls and boys, women and men, including those most marginalized
  • Implementation: Provide quality services to all, overcoming the barriers that pregnant and breastfeeding adolescent girls and those most stigmatized face
  • Response Monitoring: Monitor equitable access to services and set confidential and responsive feedback & complaint mechanisms
  • Across the Response: Engage men and boys to champion the use of family planning methods ​and to promote respectful and nonviolent relationships

The Minimum Commitments package includes three tools: (1) an introductory note and full explanation of each Minimum Commitment (Annex 26.5.23), (2) the Self-Assessment Questionnaire (Annex 26.5.24), within which guidance on scoring and an Action Plan table are provided (3) a Monitoring Form (Annex 26.5.26) (4) An orientation PowerPoint on the Minimum Commitments for Gender and Inclusion (Annex 26.5.22), providing guidance to program managers for systematic implementation of the Minimum Commitments.

 

SRHR integration with other sectors

i) SRHR and GBV

Worldwide, during times of crises, the prevalence of GBV increases due to the multiple risk factors created by emergencies as well as the ways in which existing gender inequalities are exacerbated by the chaos and tensions within households, communities and society. Potential types of GBV in emergencies may include increased levels of intimate partner violence (IPV), including marital rape and other types of physical and emotional violence; rape as a tactic of war; sexual assault or exploitation during displacement; and girls being married off as a coping strategy by households that do not have the resources to support them or a means to protect their and/or their family’s ‘honor’. To this list we must also add GBV that emerges as a result of the humanitarian response, including sexual exploitation and abuse by local, national and international aid workers, peace-keepers and security forces.

For over two decades, CARE has been implementing development and humanitarian programs to prevent and respond to GBV. These programs include transforming unequal gender power relations within households and communities; working with communities to shift social norms that subordinate women and girls and condone violence as a means to control them; engaging men and boys in addressing GBV; responding to the immediate and long-term needs of GBV survivors including their sexual and reproductive health (SRH) needs and developing livelihoods opportunities; and supporting governments to develop and implement policies, legislation and commitments to end the violence.

The CARE 2020 Program Strategy on the Right to a Life Free from Violence refers to a two-pronged approach to preventing GBV; focused-or standalone–programming; and integration across all programming.

CARE’s GBViE framework (Annex 26.5. 31) highlights 6 key programming principles, including access to provide appropriate gender and age-sensitive sexual and reproductive health in emergency (SRHRiE) services.

CARE has also developed a tool (Annex 26.5.30) for SRH and GBV service integration.

ii) Public Health Emergencies

Public health emergencies (PHEs) are likely to emerge in the midst of other humanitarian crises, or they may trigger a humanitarian crisis on their own, as we are seeing with the COVID-19 pandemic today. As PHEs will inevitably overlap with CARE’s work, preventing and responding to them effectively is critical for CARE’s work across the humanitarian-development continuum.

In order to reduce the negative impact that disease outbreaks have on communities and their health systems, CARE is working to integrate PHE preparedness activities that support prevention and early detection of infectious diseases into community-based approaches, particularly in fragile settings.

CARE’s PHE approach focuses primarily on risk communication and community engagement (RCCE), and community-based surveillance.

What is Community-based Surveillance (CBS)?  

CBS involves engaging the community to be aware of and immediately report potential public health risks1. Community members look for unusual occurrences or events in humans, animals, and/or the environment which may be a risk to their communities. Trained CBS focal points are asked to:

 

  1. Look for the occurrence of events/public health risks.
  2. Listen for other community members talking about events.
  3. Record/write down information and details about the event that you have heard about or found.
  4. Report/tell someone (your supervisor) who will be able to find out more information and confirm if the event is a threat to the community or not.

Why is CBS important?

CBS helps to reduce the spread of disease, suffering and death in communities. By supporting disease detection at the community-level, CBS can help close the gap between community and health facility level detection of disease and provide critical information to prompt faster responses.

How does CBS fit within CARE’s work?

As much of CARE’s work is rooted in strong community engagement, CARE has the opportunity to contribute to improved disease prevention, rapid detection and response in the communities where we support. These efforts may be particularly important in communities that have a high risk of experiencing a disease outbreak or are in the midst of an outbreak.

When to consider integrating CBS into CARE programming?

  • When CARE is operating in a high-risk area for disease outbreaks (e.g. post-flood) or during an outbreak
  • When CARE is supporting SRHR/health programming that includes a community-based component and can serve as a strong platform for integration

What tools can I use to support the integration of CBS?

Suggested indicators2:

  • # of PHE-related health sessions conducted in the community
  • # and % of CBS focal points who submitted reports this month
  • % of affected households who report that they have received appropriate information on communicable disease-related risks and preventive action

Where has CARE supported CBS?

  • Democratic Republic of Congo
  • 2018-present: CBS implemented before, during and after a cholera outbreak in Bipemba district in DRC’s Kasai region. Funded by CDC, the project aims to enhance prevention and early detection of disease through improved risk communication, community engagement and community-based surveillance.
  • South Sudan
  • 2019-present: CBS introduced in ‘high-risk areas’ as part of Ebola virus disease preparedness. Funded by CDC, the project aims to enhance risk communication, community engagement and community-based surveillance in Wau and Torit counties.

Who can I contact for support?

Additional Resources for Risk Communication and Community Engagement:

iii) SRHR and Cash Voucher Assistance 

Cash and Voucher Assistance (CVA): CVA refers to all programs where cash (or vouchers for goods or services) are directly provided to beneficiaries. In the context of humanitarian and development assistance, the term is used to refer to the provision of cash or vouchers given to individuals, household or community recipients; not to governments or other state actors. CVA covers all modalities of cash-based assistance except for remittances, microfinance in humanitarian interventions (although microfinance and money transfer institutions may be used for the actual delivery of cash) and payment of salaries.

The term can be used interchangeably with Cash Based Interventions, Cash Based Assistance, and Cash Based Transfers.

Why use CVA interventions within SRHRiE Programming?

A substantial body of evidence shows that giving vulnerable people money instead of in-kind assistance allows them to meet a variety of needs, support local markets while making aid budgets go further. There is consensus that cash programming is more efficient, effective and better for beneficiaries than other forms of assistance and it is becoming the modality of choice for a growing number of donors – institutional and private.

CARE’s global focus to empower women and girls, elevate their voices and attend to their needs in humanitarian crises, is highly dependent on understanding the evidence related to the risks and opportunities that come with cash programming. When markets are functional, and money is the most appropriate way to fulfil an identified need, cash programming can provide real choice and true empowerment. Giving people the most dignified form of assistance speaks to who we are as an organization. It also resounds with global commitments we have made. CARE is a signatory to the Grand Bargain – an agreement between UN, NGOs and Governments for reforming aid – which calls for better quality and more widespread use of it.

Cash-based assistance for healthcare: According to Sphere, The Universal Health Coverage 2030 targets state that people should receive healthcare without undue financial hardship. There is no clear evidence that using cash-based assistance specifically for health responses in humanitarian contexts has a positive impact on health outcomes.

Experience suggests that using cash-based assistance for health responses may help if:

·        the emergency has stabilised;

·        there is a predictable service to support, such as antenatal care or chronic disease management;

·        there is existing positive health-seeking behaviour and high demand and/or efforts are needed to improve health-seeking behaviours; and

·        other critical household needs such as food and shelter have been met.

Tips and Suggestions for CVA Integration into SRHR Activities/Outcomes

Training of healthcare providers

  • Cash grant that is restricted to it being used to attend a CARE approved training course. Cash grant should be calculated so it can cover course fees, materials etc.
  • Providing a monthly cash transfer alongside the cash grant mentioned above, to support with monthly household living expenditure so people can afford to partake in the course and still  meet their household needs.

Preventing maternal and newborn morbidity

  • Combine access to maternal and neo-natal healthcare with cash or food vouchers to support diet diversity and food consumption for
    the mother.
  • Enhance access to primary healthcare facilities by providing pregnant/new mother’s cash transfers so she can access transport (for
    reaching health facilities, particularly for life-saving services such as emergency obstetric and newborn care).
  • Cash/voucher support to procure medication and/or contraception at private pharmacies if individual for prescription refills and
    access to health facilities are limited.

Supporting survivors of GBV

  • Temporary re-location needs for those accessing safe spaces: Provide cash transfers to meet immediate needs/replace basic items
    for people who need to remove themselves from a dangerous situation, complementing safe spaces.

Reducing the risk of transactional sex as a negative coping strategy

  • Prioritize cash/voucher support to meet household needs, for those who fit the profile as being identified as a particular risk for engaging in transactional sex as a coping strategy.
  • In order to achieve an impact on severe negative coping strategies, whilst ensuring exit in a sustainable manner, predictable cash transfers over a period of more than 6 months are essential in order to establish exit strategy interventions.
  • Develop and link with VSLA structures to support a sustainable exit through encouraging savings and livelihoods creation.
  • Support at risk women and girls with skills training programmes. A labour market assessment should be undertaken to determine the skill gaps that are in demand. Depending on the skills gaps that are identified, link participants with appropriate suppliers, traders and consumers.

Accessing legal/mediation/law enforcement services:

  •  If it is identified that legal, mediation or law enforcement services are far/unavailable and require transport t (often multiple times), but transport cost is a prohibitive barrier in accessing services, people should be provided with cash transfers to address this barrier.
  • In terms of those requiring legal support, there can be other fees for progressing a case.