3. What to do: Response options
Included below is a checklist of health activities that should be implemented in an emergency response. Recognizing the capacity of the country office, the country office should identify which areas of focus they can prioritize and coordinate with coordinating groups such as the health and protection cluster meetings, under which SGBV and RH working groups function, to determine what other actors are doing to ensure a comprehensive response. Further information on each health issue is addressed in later sections of this chapter.
Checklist for emergency health and SRHR response
Support health systems and infrastructure
- Urgent: If health services are not available in the crisis-affected area, an urgent action is to provide or support health infrastructure and to distribute equipment and supplies to health workers to facilitate initiation of health services.
- High priority: If there is crowding and a lack of sanitation or water, a high priority action is to conduct disease surveillance and outbreak management.
- Longer-term priority: In all crisis support and (re)build capacity of health policies and systems.
Address priority communicable diseases
- Prevent and treat diarrhoeal diseases especially among children under 5.
- Acute respiratory infections (ARIs).
- Malaria and other vector-borne diseases.
- HIV/AIDS and other STIs.
Address sexual reproductive health needs through MISP implementation (Minimum Initial Service Package) in Humanitarian Situations
- RH coordination: identify or nominate an RH officer to coordinate SRH activities in collaboration with the health cluster, under SRH sub-cluster, if available.
- Gender-based violence: Prevent and manage consequences of GBV including treatment.
- HIV/AIDS: address HIV prevention and transmission through enforcing standard precaution, free condom distribution
- Maternal and newborn health: ensuring availability and accessibility of EmONC
- Transition to comprehensive reproductive health services including full range of contraceptive services
Address non-communicable diseases
- Trauma and injury.
- Psychosocial and mental health needs.
- Chronic diseases such as heart disease, insulin-dependent diabetes, high blood pressure.
Responding to health and SRH needs in an emergency requires a basic level of sectoral capacity within the CO. It also requires a high level of coordination with other actors involved in the health sector response before and during an emergency. The following checklist can help ensure the CO has the appropriate capacity to participate effectively in an emergency response to health and sexual and reproductive health needs.
Checklist for CO level SRH and health sector capacity assessment
- All COs should be aware of appropriate measures to respond to health and sexual and reproductive health needs. This is usually built into scenario planning exercise in EPP with special reference to SRH integration.
- Integrate a disaster risk reduction (DRR) approach into preparedness and response. See chapter 34 for more information on DRR.
- Ensure that staff from COs are represented and participating in UN health cluster (led by WHO) and other health related coordination meetings such as the GBV and RH working groups.
- Be aware of local and national health authorities’ proposed roles and other organisations that the health authorities have recognised as potential partners in an emergency.
- Integrate into CO rapid assessment procedures key information on essential health issues including sexual and reproductive health, IMCI, malaria, tuberculosis, measles, other communicable diseases, and HIV/AIDS.
- For all intervention areas selected, ensure use of the latest technical guidelines and integrate standards to monitor quality and accountability.
- Provide training for technical and non-technical staff and members of ERT in SRHR response, including other essential health areas like IMCI.
- Include simple measures to ensure the needs of mothers, pregnant women, young children and infants are met in the early stages of an emergency in CO emergency response protocols.
- Make all CO staff aware of promoting and maintaining exclusive breastfeeding in infants up to six months of age.
- Coordinate with food and nutrition security sector for addressing ongoing nutritional needs of pregnant and lactating women and that of infants.
- Ensure that health responses are designed and implemented in a way that minimizes conflict between armed groups, works actively to prevent sexual and other forms of interpersonal violence.
- Involve first responders, especially women’s groups in the planning and management of basic health and SRH interventions.
For detailed technical guidelines on supporting health systems and infrastructure, refer to Annex 26.5.1 Humanitarian Charter and Minimum Standards in Disaster Response (Sphere handbook), Annex 26.5.2 for WHO Health Cluster Resources, and Annex 26.5.3 Médecines Sans Frontières. Refugee health: An approach to emergency situations.
3.3.1 Health policies and systems
The host country’s Ministry of Health (MOH) should lead the health sector response to any emergency, where possible. International assistance and resources should support the local MOH infrastructure and human capacity to assist with the extra burden of patients, and to repair damage to the health system and infrastructure caused by the emergency. When the MOH lacks the capacity to assume the leadership role of the health sector, a UN or other agency will often take on the responsibility for a temporary period of time.
All assistance provided by international NGOs should be provided in line with national health policies and systems. In cases where the health policies and systems are inadequate or have been destroyed due to the crisis (for example, in complex humanitarian emergencies characterised by state failure), international recovery and assistance efforts may include support to re-establish basic policies, systems and infrastructure, based on international best practices on the specific specialist areas of care.
The following key principles should be kept in mind when supporting national health systems:
- Health facility levels that should be considered and reviewed for capacity include a referral hospital, central health facility (health centre), peripheral health facilities (health posts) and home visits.
- These levels of capacity, as well as health standards and guidelines, should fall in line with the host country’s national policies.
- If policies are outdated, the MOH and other organisations supporting health should make revisions based on the most current evidence-based practice as shared by the Health Cluster and harmonizing with other existing internationally accepted guidelines.
- It is preferable that local staff and facilities should be used.
- Fees and lack of infrastructure such as laboratories, referral systems and other resources should be examined to determine if they hinder access or availability to health services.
- Any changes to any health systems or infrastructure, including upgrades to better accommodate those affected by an emergency, need to be made in collaboration with the MOH.
Local populations close to where response efforts are being made will also be affected, in particular with outbreaks of communicable diseases. It is essential that the local population is not overlooked and decisions about access and services need to be inclusive of the local population, including women and adolescent groups, as they may often have to rely on that same system to treat and prevent illnesses or mortality.
3.3.2 Health surveillance systems and outbreak management
Surveillance is used to provide regular information for decision-making in an emergency. Data collected for surveillance involves quantitative figures and analysis, which are used to determine the vulnerability of the crisis-affected community and sudden changes occurring in the area where the population is being hosted in the case of displaced populations. In an emergency response, the surveillance system should be standardised across authorities and organisations, with a designated agency collecting confidential epidemiological reports with supplementary data from health facilities and other agencies engaged in response. Any CARE health response should be coordinated and linked into this system.
The health surveillance system should provide an early warning component to track and respond to an illness, and manage any potential outbreak. Case fatality rates are aligned with particular illnesses and should not exceed the following prevalence for these identified illnesses:
- Cholera: 1% or lower
- Shigella (dysentery): 1% or lower
- Typhoid: 1% or lower.
As soon as an outbreak is identified-preferably within 24 hours of recognising the disease- appropriate control measures need to be put in place. Appropriate outbreak management requires the following:
- Staff and individuals engaged in first-line response for a medical threat or emergency should be ready to respond to an outbreak with an investigation and control plan that meets current protocols and standards.
- Health systems should be equipped with laboratories to respond to outbreaks quickly, as well as be able to diagnose and treat malaria and tuberculosis, and provide assistance for vector control.
- Stocks of essential drugs and contraceptive commodities should be readily available with methods for rapid procurement if necessary.
- Isolation sites should be available within the response site with transportation available to move specimens to laboratories locally, regionally, nationally or to another country to provide confirmation on the illness.
3.3.3 Health infrastructure, equipment and supplies
Disaster and emergencies often lead to destruction or loss of critical health infrastructure and equipment, and depletion of medical supplies, including essential drugs. International humanitarian agencies are often requested to support the restoration or resupply of health infrastructure, equipment and supplies as part of the emergency response.
These responses are best managed by national health authorities with the support of the WHO and UNFPA, particularly the supply of essential drugs, equipment, and supplies related to sexual and reproductive health, e.g. emergency obstetric care, family planning/contraceptive needs. If the national and international health authorities are unable to fulfill these needs, there are times when it is appropriate for NGOs to consider supporting rehabilitation and reconstruction of health facilities, supply of basic health equipment, supplies and medications. For example, CARE has implemented this kind of response in the West Bank and Gaza, Iraq, Indonesia, and Syria among other places.
If considering this type of response, the following must be kept in mind:
- Ongoing provision of essential supplies for the health sector must be the responsibility of national authorities (with the support of WHO and UNFPA), and any support should aim to help responsible authorities restore this capacity as soon as possible.
- Procurement of health and medical supplies requires specialist expertise and should not be undertaken by general procurement staff without a specialist health or medical procurement advisor.
- Procurement or import of drugs must be consistent with national and international laws, including the country’s approved essential drugs list. Donor governments will often also have specific regulations governing the procurement of drugs.
- Rehabilitation or reconstruction of health and medical facilities also requires specialist expertise in health and medical design and construction.
WHO and UNICEF offer standardized, pre-packaged inter-agency emergency health kits that are designed to meet the primary health care needs of a displaced population without medical facilities, or a population with disrupted medical facilities in the immediate after math of a natural disaster or during an emergency. The IEHK 2011 consists of two different sets of medicines and medical devices, named a basic unit and a supplementary unit.
Basic unit contains: essential medicines and medical devices that can be used by primary health care workers with limited training. It contains oral and topical medicines, none of which are injectable.
Supplementary unit contains: essential medicines and medical devices for 10,000 people, and is used only by professional health workers or physicians. It does not contain any medicines or devices from the basic unit and can therefore only be used when these are available as well.
It should be noted that the basic and supplementary units are not intended to enable health care workers to treat rare diseases or major surgical cases. Nor is it intended for nor is designed for immunization or nutritional programs. IEHKs can be procured from UNICEF in country or through the UNICEF Supply Division in Denmark. Alternatively, they can be procured through IDA Foundation and WHO.
Specifically in relation to sexual and reproductive health (see section 3.6) UNFPA, UNICEF and USAID often provide stocks necessary for basic sexual and reproductive (SRH) services including the Minimum Initial Service Package (MISP). UNFPA offers standardized, pre-packaged emergency reproductive health kits (RH Kits) that contain enough essential medicines, supplies and equipment to meet the needs of displaced populations without medical facilities (or where medical facilities are disrupted during a crisis) for a three month period. They are intended for use during the initial phase of an emergency.
There are 12 RH kits in total. They are divided into3 different blocks according to population size and health service delivery level. They can be procured from UNFPA in country or through UNFPA’s Humanitarian Response Branch in Denmark.
To view how the kits correspond to the various components of the MISP, refer to the MISP cheat sheet. Refer toAnnex 8.5.3 for information on how to order RH kits if they are not available locally through UNFPA or whomever is responsible for coordinating RH activities.
It must be emphasized that, although supplying medicines and medical devices in standard pre-packaged kits is convenient early in an emergency, specific local needs must be assessed as soon as possible and further supplies must be ordered accordingly. Therefore, once basic reproductive health have been established, the reproductive health coordinator should assess reproductive health needs and reorder medicines, disposables and equipment based on consumption of these items, in order to ensure that the reproductive health program can be sustained. All efforts should be made to strengthen or develop a medical supplies logistics management information system. Re-ordering should be done through regular channels (via the national procurement system, nongovernmental organizations – NGOs – or other agencies) or through the UNFPA Procurement Services Branch in Denmark.
3.3.4 Health workforce and training
Health systems during emergencies also experience a significant decrease of available health workers in addition to having supplies and facilities issues. Many of the countries experiencing a humanitarian crisis are already wrestling with low resources, resulting in a weak health system with strained human resources for health. Emergencies exacerbate these shortages and compromise human and infrastructure safety, capacity and quality. Moreover, crises and emergencies can greatly increase the percentage of the population in need of immediate health care. A competent and capable workforce is necessary to implement essential health services during these time periods, including services for sexual and reproductive health.
Trained obstetric and gynaecologists are qualified human resources for providing comprehensive reproductive health services. These include being able to provide a full range of clinical services including Caesarean Section for complicated pregnancies, as well as other gynaecological surgeries required for saving women’s lives. Health facilities need to be fully equipped to provide this highest level of services. However, most of the maternal deaths occur due to a few frequently occurring complications, which if managed properly and in a timely manner can be prevented. Almost all of maternal deaths occur in low resource setting and in developing countries. Getting the right health care provider, especially skilled birth attendants, is a proven best practice for preventing excessive maternal deaths.
In addition to Obstetricians and gynaecologists, other providers like general practitioners, mid-wives, nurses, clinical officers and health assistants can also provide good quality reproductive health services. During a humanitarian emergency, these providers who are trained in sexual and reproductive health skills can provide valuable health services to prevent maternal and neonatal deaths. As far as possible, during an emergency every effort should be made to hire trained providers who can provide good quality sexual and reproductive health services.
At the onset of a crisis, it is essential to find providers who are well trained in SRH skills to initiate quality service delivery as quickly as possible. There is very little scope for introducing training for providers at this stage. Once the situation has stabilized and the emergency response is better resourced, more in-depth training can occur to increase the workforce and include more local workforce to assist in efforts to meet demand for services. High intensity refresher training in sexual and reproductive health care can be organized to cover skills with discreet modules of basic emergency obstetric care (BEmOC), contraceptive counselling, and other basic integrated SRHR services. High intensity refresher training for long acting reversible contraceptive (LARC) methods can also be conducted to meet the demand for these services. Ensuring a competent health workforce for SRHR services is essential for preventing and reducing high maternal mortality and morbidity in humanitarian settings. For example, ensuring skilled birth attendants (SBA) to assist in births is considered best practices to reduce maternal mortality and morbidity. For SRHR program design and training needs COs can contact the SRHR global team for assistance. Ref to contact information at the beginning of the Health and SRHR section.
3.3.5 Case Study – SAF-PAC Initiative
Supporting Access to Family Planning and Post-Abortion Care Initiative (SAF-PAC)
The ongoing Supporting Access to Family Planning and Post-Abortion Care (SAFPAC) initiative led by CARE, is an example of programming that addresses the strains on health infrastructure and workforce in crisis situations. Since its beginning in 2011, the project has provided contraceptives, including long-acting reversible contraceptives (LARCs), to refugees, internally displaced persons, and conflict-affected resident populations in Chad, the Democratic Republic of the Congo (DRC), Djibouti, Mali, and Pakistan.
SAFPAC’s strategy focuses on 4 broad interventions drawn from public health best practices in more stable settings: competency-based training for providers, improved supply chain management, regular supervision, and community mobilization to influence attitudes and norms related to family planning. The approach promotes sustainability by establishing in-country training centers to build capacity in clinical skills training and supervision of new providers. In addition, monthly supervision using simple checklists has improved program and service quality, particularly with infection prevention procedures and stock management. We have generally instituted a “pull” system to manage commodities and other supplies, whereby health facilities place resupply orders as needed based on actual consumption patterns and stock-alert thresholds. Finally, reaching the community with mobilization efforts appropriate to the cultural context has been integral to meeting unmet family planning needs rapidly in these crisis-affected settings. Despite the constraints in crisis-affected countries, such as travel difficulties due to security issues, in our experience, we have been able to extend access to a range of contraceptive methods, including long-acting reversible contraceptives, in such settings using best practice approaches established in more stable environments.
Between July 2011 and December 2013, the initiative reached 52,616 new users of modern contraceptive methods across the 5 countries (catchment population of 698,053 women of reproductive age), 61% of whom chose long-acting methods of implants or intrauterine devices. The percentage of new users choosing LARCs varied by country: 78% in the DRC, 72% in Chad, and 51% in Mali, but only 29% in Pakistan. In Djibouti, those methods were not offered in the country through SAFPAC during the period discussed here. In Chad, the DRC, and Mali, implants have been the most popular LARC method, while in Pakistan the IUD has been more popular. Use of IUDs, however, has comprised a larger share of the method mix over time in all 4 of these countries. These results to date suggest that it is feasible to work with the public sector in fragile, crisis-affected states to deliver a wide range of quality family planning services, to do so rapidly, and to see a dramatic increase in the percentage of users choosing long-acting reversible methods.
Adapted from “Delivery High Quality Family Planning Services in Crisis Affected Settings” article series published in Global Health: Science and Practice (GHSP). Training Materials
For detailed technical guidelines addressing communicable diseases, refer to Annex 26.5.1 Humanitarian Charter and Minimum Standards in Disaster Response (Sphere handbook), and Annex 26.5.3 Médecines Sans Frontières.Refugee health: An approach to emergency situations.
Prevention and treatment of communicable diseases is a critical, life-saving priority in any emergency response. The prevention of communicable diseases requires interventions across sectors-water, sanitation and hygiene (refer to Chapter 24 Water, sanitation and hygiene (WASH)), shelter (Chapter 8.2 Shelter and camp management) and food security (Chapter 8.3 Food security). Health sector interventions should be closely integrated with responses in these other sectors. The key basic interventions to address priority communicable diseases are listed in the checklist below.
Checklist – interventions to address priority communicable diseases
- Provide an adequate and accessible supply of water (refer to Chapter 24 Water, sanitation and hygiene (WASH)).
- Ensure an adequate system for human excreta is provided.
- Provide soap in sufficient quantities, with education on environmental, food and personal hygiene.
- Monitor bloody and non-bloody diarrhoeal disease through surveillance systems, and be prepared to respond to any disease outbreak.
- Ensure oral rehydration therapy is in place to treat people suffering from diarrhoeal disease.
- Ensure proper shelters are provided to reduce overcrowding and limit chilling in infants with the provision of blankets (Refer to Chapter 8.2 Shelter and camp management).
- Put in place a regular and adequate food ration for everyone, with promotion of breastfeeding (refer to Chapter 8.3 Food security, and Chapter 9.8 Infant and young child feeding in emergencies).
- Administer supplements of vitamin A.
- Work with partners to ensure all children between six months and 15 years of age have received a measles vaccine.
- Provide vaccines for pertussis (whooping cough) and diphtheria.
- Ensure all pregnant and lactating women, and children under five years of age, receive an insecticide-treated bed net.
- Ensure universal precautions are practiced by all who come in contact with blood and body fluids.
3.4.1 Diarrhoeal diseases
In emergencies, diarrhoeal diseases are a major cause of morbidity and mortality. Inadequate water supplies, substandard and insufficient sanitation facilities, overcrowding, poor hygiene, scarcity of soap and malnutrition are the main factors contributing to the occurrence. Malnutrition and diarrhoeal diseases are closely linked: malnutrition contributes to the severity of diarrhoea, and diarrhoea can cause malnutrition. The most common diarrhoeal diseases are shigellosis (the most frequent cause of dysentery), cholera, rotavirus, and e-coli bacillus.
Routine surveillance systems should include indicators to track cases of bloody and non-bloody diarrhoea for all children. Adult mortality, increases in numbers of adult cases, significant increases in bloody diarrhoea, and a rise in the case fatality rate should be an indication to alert medical staff immediately.
Use of oral rehydration therapy (ORT) in accordance with early rehydration is the most critical element to treat and prevent severe morbidity or mortality. In the early phase of the emergency, at least one ORT corner should be set up immediately in the most central health facility with a plan for rapid scale-up to better accommodate the population.
3.4.2 Acute respiratory infections (ARIs)
Much morbidity and mortality can also be attributed to acute respiratory infections (ARIs). Conditions that foster the spread of infections include overcrowding, indoor fires, and inadequate shelter and blankets, especially in cold climates. Interventions that are effective in helping to reduce the incidence of ARIs include: vaccinations for measles, diphtheria and pertussis; supplements of vitamin A; and breastfeeding children under two years of age.
3.4.3 Measles and immunisation
Throughout the world, measles is still one of the leading causes of childhood mortality. It is a highly contagious disease and can be associated with high mortality, severe complications and an increased vulnerability to other infections, which can subsequently lead to malnutrition. When vaccinations are not promptly distributed, populations are vulnerable to outbreaks.
Prevention of measles is thus a high priority, particularly when the population is living in refugee camps or displaced person situations. Measles immunisation campaigns should be prioritised, along with immunisation for pertussis and diphtheria when determined through surveillance. Surveillance should be used to determine when it is appropriate for other vaccine programmes to be integrated into health services.
During a humanitarian response CARE will focus on strengthening or introducing SRHR services, either through collaboration with local ministries of health, or in partnership with other non-governmental organization implementing partners. However, CARE has an important role to play, where feasible, in assisting the local and national governments in contributing to reducing maternal, newborn, infant and under-five mortality and morbidity through programs introduced by the public sector of the concerned government. In the absence of a functioning government health system, CARE will assist, where feasible, with multilateral organizations to support life-saving interventions to reduce excessive maternal and newborn, including infant and under-five morbidity and mortality.
To ensure prevention and detection of measles in an emergency, the following points should be adhered to:
- At the outset of an emergency, an estimation of measles vaccination of all individuals aged nine months to 15 years of age should be made.
- If coverage is estimated to be less than 90%, then a mass vaccination campaign should be initiated in coordination with local and national health authorities, as well as partner organisations.
- Upon completion of the measles campaign, at least 95% of the population aged six months to 15 years of age must have received the measles vaccine.
- During this time, at least 95% of children six to 59 months of age should also receive an appropriate dose of vitamin A.
- Routine follow-up with another measles vaccination dose nine months later should be in place with children six to nine months of age.
- Fixed vaccination points should be immediately integrated into the health system with the collaboration of local and national health authorities.
- At least 95% of all newcomers into the host area should be vaccinated.
- All suspect cases for measles should be assessed immediately.
In addition to mass measles vaccinations, standardised case management protocols, such as the IMCI for diagnosis and treatment, should be used. Outreach activities and community education messages should be widely disseminated to ensure that individuals affected by the emergency are aware of when they should seek treatment or care.
3.4.4 Vector-borne diseases
In the early phase of an emergency, rapid assessment should determine the risk for malaria infection in the disaster location. In the case of displaced or refugee populations, determine where the population is settling and compare it to the area the population is relocating from. Some level of treatment and/or prevention should be considered, including distribution of treated bed nets and health promotion of malaria prevention.
Malaria infection during pregnancy is a significant public health problem with substantial risks for the pregnant woman, her fetus, and the newborn child. In parts of the world where malaria is endemic, it may directly contribute to almost 25% of all maternal deaths. In high-transmission settings, where levels of acquired immunity tend to be high, infection may be asymptomatic in pregnancy. However it still contributes to maternal anemia. Both maternal and placental parasitaemia can lead to low birth weight, which is an important contributor to infant mortality. In low-transmission setting, malaria in pregnancy is associated with anemia, an increased risk of severe malaria and may also lead to spontaneous abortion, stillbirth, prematurity and low birth weight.
In settings where malaria is a problem, programs should use long-lasting insecticidal nets (LLINs), and prompt diagnosis and effective treatment of malaria infections.
Displaced populations may find themselves at a greater risk for malaria infection. If the population settles in a malaria endemic region, laboratories, means for vector control and the most appropriate drug treatment for the region will need to be considered in the relief effort. For populations travelling into a non-endemic region from an endemic region, drug treatments should be available to treat cases that might develop. In addition, surveillance should monitor malaria incidence, as the mosquito may also travel with the population and result in spread in the current location.
3.4.5 Prevention of HIV/AIDS
As social networks and livelihoods collapse due to emergencies and conflicts, people are subjected to situations that are known to increase their vulnerability and risk to HIV. An individual’s access to information and services-including prevention information, condoms or health care-is either limited or completely cut off.
Loss of livelihoods and income may force women and adolescent girls into transactional or commercial sex; many women have to trade sex for food or security, making contraception a necessity. Increased interaction between military, peacekeepers and local populations also put women and men at risk of contracting HIV and other sexually transmitted infections (STIs), especially when they practise unsafe sex (without condoms). Women and girls seldom have control over sexual negotiation or the relationship. Men who have sex with men (MSM) as well as LGBT populations may be disproportionately affected and marginalized, so may need particular attention in service delivery for HIV prevention/treatment as well as other STIs.
A minimum package of services should be in place to prevent transmission of HIV/AIDS among the population affected by the emergency. This includes free condoms, safe blood supply, universal precautions for infection prevention, relevant information and education, case management of STIs, and basic health care for people living with HIV/AIDS. HIV control activities should be continually informed by assessing local needs and circumstances. See also Chapter 41 HIV/AIDS. Refer to Annex 26.5.6 for a list of the minimum requirements for infection control.
Vertical transmission of HIV from mother to child must also be considered in the prevention response. Current guidelines recommend that all pregnant women of unknown status be offered HIV testing and counseling, and that all women testing HIV+ should receive an appropriate prophylactic regimen to reduce the chance of HIV transmission during delivery and post-partum. HIV+ mothers should also receive counselling on exclusive breastfeeding of infants for the first 6 months to further reduce the chances of transmission of the virus.
HIV control activities should be continually informed by assessing local needs and circumstances. See also Chapter 9.3 HIV/AIDS. Refer to Annex 26.5.7 for a list of the minimum requirements for infection control and for UNAIDS best practices on HIV and emergencies.
Sexual and reproductive health is an important component in a humanitarian response, and providing essential sexual, reproductive health (SRH) services saves lives. “Reproductive health (RH) care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving RH problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases.” – International Conference on Population and Development (ICPD) Programme of Action.
Sexual and Reproductive Health and Rights (SRHR) is a core pillar of CARE’s work in empowering women and girls as well as a core health service defined by Sphere. Our goal in the challenging environments of emergencies, post-conflict and disaster settings is to protect the health and well-being of women, girls, men, and boys and to promote gender equality by increasing access to essential SRHR services and programs across all phases of the emergency continuum (preparedness, response, and transition). For more information on the SRHR strategy within CARE, reference “CARE’s Sexual, Reproductive and Maternal Health and Rights Program Strategy” document.
Effects of a Crisis on Sexual and Reproductive Health
Women and children, who normally comprise 75 – 80% of displaced populations, suffer disproportionately compared to populations living in stable situations. In crisis situations, we know that forms of gender-based violence frequently increase dramatically in both conflict-related and natural disasters; family planning (FP)/voluntary contraception (VC) and maternal newborn care services including emergency obstetric care (EmOC) are frequently unavailable; the risk of HIV and STI infection continues due to lack of information and access to condoms along with the need to continue treatment and support for those infected with HIV/AIDS.
In a crisis affected population, approximately 4 per cent of the population is estimated to be pregnant. Of the more than 100 million people in need of humanitarian assistance in 2015, an estimated one quarter were women and adolescent girls of reproductive age (SOWP, UNFPA 2015). Approximately 15 per cent of all pregnant women will experience an unpredictable obstetric complication during pregnancy or childbirth that will require emergency obstetric care. Out of this 5 – 15 per cent of all deliveries will require surgery, such as C-section. In order to prevent maternal and newborn mortality and morbidity resulting from complications, skilled birth attendants at all births is a proven best practice, along with basic emergency obstetric care and neonatal resuscitation. Voluntary contraception services is well proven and time tested intervention that reduces maternal and newborn mortality. Voluntary contraception can prevent approximately 30% of maternal deaths and also prevents maternal to child transmission (PMTCT) of HIV (Saifuddin et.al., 2012). Malnutrition and epidemics, which are common occurrences in humanitarian settings, increases the risk of pregnancy complications. Childbirth occurs on the wayside during population movements and lack of access to comprehensive EmONC increases risk of maternal death and neonatal deaths.
For RH services to be comprehensive, it is critical that all of the following elements are implemented at the earliest possible opportunity:
- Maternal newborn care that includes emergency obstetric and newborn care (EmONC) and post-abortion care (PAC).
- Voluntary contraception including short acting, long-acting reversible contraception (LARC) as well as emergency contraception (EC).
- HIV prevention, basic care for those infected with HIV and continued medical treatment for those already on antiretroviral treatment (ART).
- Prevention and treatment of sexually transmitted infections (STIs).
- Prevention and treatment of gender-based violence (GBV) including medical, psychosocial and economic care and support; legal services; and security.
Checklist – SRHR Background and MISP readiness checklist
Pre-emergency Basic SRHR Background Information Checklist:
- Where did women go for delivery services and emergency obstetric and newborn care services? How was the quality of services? What is the Maternal Mortality Ratio (MMR)?
- Where did people go for HIV/AIDS treatment and support? Are people taking antiretrovirals (ARVs)?
- Do women and men use contraceptive services? What was the contraceptive prevalence rate (CPR)? What were the most commonly used methods?
- Are there local women’s groups and associations working on GBV prevention, psychosocial care, judicial support and economic reintegration?
- Are health facility staff trained to provide clinical care for survivors of sexual violence?
- Is there a focal point within CARE to coordinate and implement the MISP activities for sexual and reproductive health within CARE’s emergency response activities
- Is there an existing RH coordination mechanism (frequently led by UNFPA) and is CARE coordinating all RH (and health) programming with them
Minimum Initial Service Package (MISP) for RH Checklist:
- Reduce HIV transmission by:
- establishing conditions needed to comply with universal precautions
- making male and female condoms available for free
- keeping ready and providing free post-exposure prophylaxis (PEP) for any individual who may have had unprotected sex or been raped (sub-kit 3 from UNFPA, see Annex 26.5.12 )
- ensuring essential PMTCT services (including HIV testing) are available for pregnant women.
- Reduce HIV mortality by:
- ensuring that patients already on ART can access their medicines, and that ARVs being provided match existing regimens for the population.
- Prevent excess neonatal and maternal morbidity and mortality by:
- providing clean delivery kits for mothers or birth attendants
- providing midwife delivery kits (UNICEF or UNFPA) to the health facility
- promoting exclusive breastfeeding for infants up to six months of age
- establishing a referral system to manage obstetric emergencies
- Ensure access to voluntary contraception services by:
- procuring and providing modern contraceptive methods, especially LARC methods
- ensuring an appropriate method mix including short-acting, long-acting, condoms and emergency contraceptive methods
- providing safe and confidential contraceptive counselling
- promoting community awareness of where and how to receive contraceptive services
- Prevent and manage the consequences of gender-based violence by:
- assuming that it is happening and asking women how it can be prevented
- ensuring that women are involved in: leadership positions of food distribution, design and building of latrines and water points, For information on alternative fuels, please go to Annex 26.5.4.
- working to establish health, and psychosocial and legal response for survivors of violence.
- Plan for the provision of comprehensive reproductive health services integrated into primary health care, as the situation permits. This includes:
- collecting background data on maternal, infant and child mortality; HIV/AIDS prevalence (if available); and contraceptive prevalence
- identifying suitable sites for future delivery of comprehensive reproductive health (RH) services by addressing security problems, accessibility for all potential users, privacy and confidentiality during visits, easy access to water and sanitation, appropriate space for users’ waiting time, and aseptic conditions.
- Assess the staff capacity to provide comprehensive RH services and put a plan in place for training/retraining of staff. Order equipment and supplies accordingly.
Even 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) favour the rapid spread of HIV/AIDS and other STIs, and put women and adolescent girls in vulnerable situations.
The MISP is a series of activities focused on the sexual and reproductive health needs of populations in the early phase of a crisis. It can be implemented without a needs assessment, because there is documented evidence that it saves lives. The above checklist includes components of the MISP checklist. For more information on the MISP, MISP checklist, distance learning module on MISP, the Interagency Field Manual for Reproductive Health in Crisis Settings (or Field Manual) and IPPF facilitator’s manual for MISP training see Annex 26.5.5.
Emergency responses have been slow to address the spread through prevention and treatment of HIV, although both are life-saving health interventions. These trends are changing as implementers begin to understand the importance of addressing HIV at the earliest possible stage of an emergency.
ARV treatment interruption can cause unnecessary increases in morbidity and mortality, and can also lead to drug resistance. WHO advises that continuation of treatment for those already on ART prior to the crisis should be considered a priority intervention and part of the minimum initial response to HIV even in the acute phase of the emergency.
Prevention of HIV transmission from mother to child (PMTCT) during an emergency should also be a priority intervention, and appropriate national guidelines should be followed to ensure that the risks of vertical transmission are minimal.
Other methods to prevent HIV should be made free and accessible, such as providing condoms (male and female) and post-exposure prophylaxis (PEP). Universal precautions against HIV transmission should be employed.
3.5.3 Gender-based violence
Evidence demonstrates that the incidence of gender-based violence (GBV), such as sexual assault, harassment, sexual exploitation and domestic violence, increases during emergencies. There is mounting evidence of increased GBV in post-conflict situations as well. It is important to consider the root causes, contributing factors and examples of GBV when assessing, designing and implementing a GBV program (SPRINT, 2009):
- Root cases include disrespect for human rights, abuse of power, and gender inequality.
- Contributing factors include conflict, poverty, lack of education, sexual factors, physical, emotional/mental, economic, harmful traditional practices (HTP), alcohol/drug abuse, lack of police protection and lack of secure domiciles/areas.
- Examples of GBV include domestic violence, child marriage, dowry abuse, verbal emotional abuse, sexual abuse, FGM, marital rape, verbal emotional abuse based on gender, and rape.
CARE has vast experience in addressing root causes and contributing factors to GBV and country offices are encouraged to integrate this work into emergency preparedness, planning and response. GBV requires a very well coordinated multi-sectoral response that includes the following services: health, psychosocial, legal/justice, and security and protection. This response must result in addressing a protection system in place especially for women and girls, the provision of quality care for survivors, and raising awareness of services available for prevention and treatment. Survivors of sexual assault need access to quality post-rape care that includes post-exposure prophylaxis for HIV, antibiotics for sexually transmitted infections (STIs), emergency contraception, counselling and support. All programs should include a referral system that links survivors with the different services. Referral systems from outreach workers for access to health facility services, protection and legal services need to be established. Coordinate with the protection sector where applicable to create synergies between sectors and overall interventions.
Please refer to Annex 8.5.14 for clinical management guidelines and refer to Chapter 9.1 Gender, for information on how to plan and implement a quality program and for details on the non-health aspects of GBV programming. To provide these services health worker staff need training and follow-up supervision that is based on the WHO guidelines. Please refer to Annex 26.5.14 for links to the WHO Clinical Management for Rape Survivors and information on other resources for training in clinical management.
3.5.4 Maternal and newborn health
Maternal and newborn deaths and disabilities often increase in emergencies due to lack of available treatment for unexpected medical complications, even when there are trained personnel available. To promote safe deliveries, all visibly pregnant women should be given a clean delivery kit for home use. These kits may frequently be obtained from UNFPA at the country level or ordered from UNFPA (see Annex 26.5.3 for ordering information). These are packages that are used by the woman or her traditional birth attendants (TBAs) during the birth that are managed at home. A referral system for emergency obstetric care that includes transport and communication systems needs to be available 24 hours a day, seven days a week. A local referral facility should be supported with personnel, medical equipment and supplies. If this is not possible, then an appropriate emergency referral facility for the displaced population should be established.
To prevent maternal and newborn deaths, primary health care facilities should provide basic emergency obstetric and newborn care (EmONC) and the referral site should provide comprehensive EmONC. It is important to provide materials and drugs including an orientation to midwives and other skilled birth attendants on using these supplies to safely conduct deliveries, deal with complications and stabilise women before transport to the referral level. Refer to Annex 26.5.12 for MNH and EmONC resources. Supplies for these services are included in the RH kits that may be ordered through UNFPA.
3.5.5 Voluntary Contraception
Voluntary contraception is a necessary part of reproductive health service delivery. This is an important part of SRHR interventions to reduce maternal and newborn mortality and morbidity. Access to modern contraception could reduce maternal deaths, STI/HIV transmission, as well as the occurrence of unintended pregnancies and adverse consequences associated with unintended pregnancies. Method mix is essential for the acceptance and continuation of FP/VC use; therefore, services should ensure availability of short-acting (ex. barrier methods and birth control pills), and long-acting reversible (ex. IUD and implants). When the situation transitions to a more stable setting, permanent methods of contraception (such as sterilization) may be offered, based on the demand from the community. This should also include emergency contraception (EC) as a post-coital method of contraception. EC is also critical for post-rape crisis care. See GBV Section.
Contraceptive counselling should emphasize client privacy and confidentiality. Counselling must promote informed choice with description of the methods available as well as effectiveness and potential side effects of them. Full knowledge of side effects (positive and negative) have been linked to higher continuation rate of the chosen method. Currently, contraceptives are included in Kits 1,3,4,5, and 7. Refer to the WHO Medical Eligibility Criteria for Contraceptive Use and the MEC Wheel tool in Annex 26.5.16 to help identify medical conditions that determine the safety of a method based on client’s clinical conditions. The information from the MEC Wheel as well as the client’s own choice determines what contraceptive methods are best for the client.
If possible, activities to encourage community awareness of where and how to seek contraception should occur. This should be inclusive of not only women and adolescents of reproductive age, but also men and boys as well as other potential influencers – determined by analysis of the cultural context. Engaging key community religious, ethnic, or women’s group leadership and sponsoring their support can be incredibly helpful as well.
3.5.6 Postabortion and Safe abortion care
Voluntary contraception can reduce the demand for abortion; however, there will still be the need for and occurrence of abortions, especially in crisis settings. Access to safe abortion and post abortion care can reduce the occurrence of maternal mortality (UNFPA estimates by up to 50%), especially through the use of manual vacuum aspirators. Manual vacuum aspirators are critical for life-saving procedures for treating complications of abortions, both induced and spontaneous. Almost in all countries, post abortion care is an accepted best practice for managing complications of abortion. There are only a hand-full of countries that have strict regulations on providing access to safe abortion services. Almost all countries provide some conditions where abortion services are legal and life-saving. CO’s must determine their capacity to provide these services as well as their comfort level.
- Ensure that the health system has some mechanism in place to handle injury and physical trauma.
- Address mental and psychosocial health needs in the context of the emergency-refer to Chapter 8.4 Psychosocial programming. Support needs to be in place to address psycho-social health issues attributed to the emergency, as well as to support mental health needs existing prior to the emergency.
- Work with other organisations to identify an authority or agency most capable of handling individuals with chronic disease, and provide support as appropriate to ensure chronic disease is being treated in accordance with standard guidelines.
3.6.1 Trauma and injury services
The health system should be able to prioritise trauma services. It should also be able to triage patients or have a referral system in place for trauma and surgical care if the facilities are unable to cope with these situations. First aid and basic medical care at a minimum should be available within the system to help stabilise individuals. Humanitarian organisations that specialise in medical care (for example, ICRC and MSF) often provide these services in cases where the national or local health system is unable to do so.
3.6.2 Chronic diseases
Assessments and surveillance should include tracking and determining individuals who suffer from chronic disease. A specific agency should be vested with caring for patients of chronic disease. These individuals should be identified and registered, and provided necessary routine treatments with medications specified on the essential drug list. In some cases, humanitarian agencies have provided assistance by providing medication to the health system to address chronic disease in the aftermath of an emergency.
Emergencies cause significant psychological trauma for the affected populations. Ensuring that people have access to services for support, including cultural and religious events, and that lives resume a sense of normalcy soon after settling, is beneficial to the psychological well-being of the community. Health services also need to be able to address specific mental health issues. For further information on mental and social aspects of emergencies refer to Chapter 8.4 Psychosocial programming.
The West Bank and Gaza
In 2001, CARE International established an Emergency Medical Assistance Project (EMAP) in the West Bank and Gaza to respond to the crisis affecting the health system following the intifada. This crisis was due to increased emergency demands as a result of conflict-related injuries, and a fall in health and nutritional standards due to border closures and the decline of the Palestinian economy. CARE responded to the crisis by working through Palestinian non-government run health and medical services that were augmenting the health system. CARE supplied essential drugs and supplies to keep health services running. CARE also provided capacity-building to improve managerial and technical capacity, and trained community health workers to help improve access for conflict-affected communities to basic health care including first aid, midwifery and psychosocial counselling.
Democratic Republic of Congo (DRC)
In November 2008, CARE responded to the outbreak of violence in North Kivu by distributing clean delivery kits to pregnant women obtained from UNFPA as part of the NFI distribution to displaced populations residing in Goma. CARE staff participated in the SGBV working group meetings as well as health cluster and RH coordination meetings and begain SGBV activities by setting up referral systems for survivors of GBV to access medical and psychosocial care. Then in collaboration with local partners, they trained health workers in two districts on the clinical and psychosocial care of rape survivors. After training, the health facilities were supplied with equipment, supplies and medicines including PEP for HIV. Feminine hygiene supplies made from locally available materials were included in the hygiene kits distributed to women of reproductive age. Information from this program was fed into regional and international advocacy efforts that informed the UN Under-Secretary General before their visit to DRC.
Simeulue Island, Indonesia
CARE played an important role in providing essential health services in Indonesia following the 2004 South-East Asian tsunami. In Simeulue Island, mobile health clinics provided services to approximately 20,000 people in rural areas. After recognising a high incidence of malnutrition on the island, CARE prioritised the support of village-level mother-and-child health and nutrition clinics, where the greatest impact on child health could be made. Through this support, CARE worked to re-establish basic emergency reproductive health services and provided antenatal care services, reproductive health and family planning education, female hygiene kits, and safe delivery kits to pregnant women and midwives.
In June 2007, coastal areas of Pakistan were hit by cyclone Yemyin. CARE’s emergency response included providing emergency health care services to around 10,000 people, mostly women and children, through three mobile medical teams working in three flood-affected districts.