Timely Reproductive Health Interventions
adequate food, clean water, shelter, sanitation and primary health care
(PHC) are priority activities in any refugee emergency. These interventions
help combat the major killers in refugee situations: malnutrition, diarrhoeal
diseases, measles, acute respiratory infections (ARI) and malaria (where
prevalent). However, RH care is also crucial for the physical, mental
and social well being of any individual. As an integral part of PHC,
RH care is important in overcoming such problems as:
women are most affected by reproductive health problems. For refugee
women, this burden is further compounded by the precariousness of their
The Complexity of Intervening
It is important that RH interventions are not only timely but also appropriate and consistent with national laws and development priorities. RH programmes affect highly personal aspects of life, so programmes must be particularly sensitive to religious and ethical values and cultural backgrounds of the refugee population.
It may not always be feasible for one organisation to implement the full range of RH services. Providing comprehensive RH services may require cooperation and coordination among agencies.
The complexities of reproductive health were discussed at the Fourth World Conference on Women (Beijing 1995). Participants listed the following as some of the reasons why many of the world's people do not benefit from reproductive health:
"... inadequate levels of knowledge about human sexuality; inappropriate or poor-quality RH information and services; the prevalence of high-risk sexual behaviour; discriminatory social practices; negative attitudes towards women and girls; and the limited power many women and girls have over their sexual and reproductive lives."
Platform of Action, paragraph 7.3 -- Beijing 1995
"Adolescents are particularly vulnerable," they concluded.
face even greater difficulties in obtaining RH services. Among them:
Guiding Principles for Intervention
RH programme requires adequate and well-trained staff, sufficient funding,
principles are applicable to every aspect of RH assistance and to all
subsequent chapters of this Field Manual.
Community participation is essential at all stages to ensure the acceptability, appropriateness and sustainability of RH programmes. It is necessary for empowering refugees, particularly women, to have greater control over their lives and over the services that are provided to them.
In an emergency, refugees are extremely vulnerable. It may be easy to overlook their particular needs in the urgency of providing services. Their participation is vital in ensuring that this does not happen, and that the services are adapted to the users rather than vice versa. In each situation it is necessary to identify groups and channels through which participation can be fostered. However, it is also important to recognise that the leaders may not be best placed or able to provide the information and support needed to successfully adapt RH services to the population concerned. Participation may be best achieved through the family unit.
only by taking into account the cultural, economic, ethical, legal,
linguistic and religious backgrounds of the refugees and host country
population that appropriate services can be offered to and used by refugees.
By actively participating, refugees develop the sense of "ownership"
over programmes that is essential for sustainability.
through community participation that essential information will be gathered
to direct the planning of services. Such information includes:
A failure to obtain such information may have a negative impact on the use of services, for example, if family members are excluded from a birth when they have an important cultural role to play at such times.
important that both men and women be involved in many aspects of the
RH programme to promote responsible and caring attitudes and behaviour
for the benefit of all. Although men may be poorly informed about RH
matters, they are often the decision-makers. Health providers need to
be aware of the roles and decision-making process within the family
so they can provide services effectively and in the best interests of
the whole family.
RH services require that organisations, programmes and providers,
These aspects of quality of care are also guiding principles of medical ethics in the protection of human rights.
Technologies and Skills
Informed consent means that the patient not only has choices, but also can make an educated decision among various options. To make such a decision, the patient must know her/ his condition and have ample opportunity to ask questions and receive answers from a knowledgeable provider.
It is important to distinguish between different aspects of integration. Reproductive health services should be integrated into primary health care. Integration may occur in relation to the place at which services are provided or the personnel who provide those services.
The potential to integrate services provided at any particular site will depend on the skills and resources available. It is unreasonable to expect the community health worker to provide too wide a range of services. A health centre will have greater resources and more skilled personnel, and so greater integration at one site becomes possible. The referral-level facility must be able to provide services to meet all needs.
Successful integration is dependent on the quality of communication among the various personnel, at different levels, within the overall service. All personnel must be fully aware of how the system operates, what services are provided at each level, and how those who want to use the services can do so. The staff at one level must be able to provide information about all other levels. Communication must also ensure that when referrals are made between levels, adequate information is received about a patient at both ends of the service. Information must travel in both directions and must cover both the reasons for a referral and the eventual consequences of any action taken.
among levels is essential to deal satisfactorily with issues relating
to support, supervision and training, all of which are essential in
maintaining quality. Specific training of personnel may be necessary
to ensure that the designated services can be provided at each level
by appropriately skilled personnel.
should be considered neither as optional nor as special projects. They
should be integrated in a timely fashion within PHC and community service
activities. Even when the delivery of RH services calls for special
arrangements or resources, this cannot justify their postponement or
Reproductive health requires knowledge and understanding about human sexuality and appropriate, adequate and accessible information.
It is important to raise the level of knowledge about reproduction and sexuality. Women, men and adolescents should understand how their bodies work and how they can maintain good reproductive health. Scientifically validated knowledge should be shared to promote free and informed choice and to counter misperceptions and harmful practices.
IEC activities are essential for sharing this knowledge. Such activities range from "one-to-one" conversations between service providers and refugees to highly developed formal campaigns.
There are also effective IEC strategies that promote community participation and individual commitment to changing behaviours.
can be found in Appendix One.
The active promotion of reproductive health should be part of all refugee assistance programmes from the outset. A lack of awareness of the issues involved in protecting and promoting reproductive health may be found in all groups involved in a refugee setting, from the providers of health care to the community they serve. This lack of awareness may become a real barrier to improved reproductive health and responsible sexual behaviour.
opportunities to promote RH issues may be limited. Any advocacy that
is undertaken must demonstrate understanding of the culture, values
and belief systems of the local population. Advocacy that is insensitive
or disrespectful may be counterproductive and prompt rejection, or even
reprisals, within the refugee community.
is needed among:
To foster this coordination, it is recommended that an individual be identified as RH Coordinator in each refugee situation. This person would assume the responsibility for overall organisation and supervision of RH activities, as well as the integration of these services within other health services.
The issue of sexual violence provides an excellent illustration of the need to coordinate among sectors. To deal with the causes and consequences of violence, health professionals must work closely with staff in the protection and community services sectors. By doing so, staff can develop detailed procedures on appropriate care for survivors and strategies to prevent the occurrence of sexual violence.
among implementing agencies requires that, although each agency has
its own expertise and range of qualified staff, there should be a standard
approach used by all agencies involved. Even though an agency may not
provide a full range of RH services, coordination with others would
ensure that the end product is complementary and comprehensive RH care.
Uncoordinated activities result in inappropriate allocations of scarce
resources and reduced impact of the project.
must be based on the expressed needs and demands of refugees. RH needs
assessments should be carried out when the emergency situation has stabilised.
This Field Manual does not give detailed guidance on conducting needs
assessment, but refers the field staff to a set of tools created by
the Reproductive Health for Refugees (RHR) Consortium for this purpose.
(See Further Reading)
RH needs assessment tools have been developed by the RHR Consortium:
These tools assist relief workers in gathering information to assess attitudes toward RH practices, local medical practices and policies, the scope of needed services and the degree to which current services provide what is needed.
which should be adapted to each situation, are designed to be used by
people with field management experience and/ or RH experience to design
new RH programmes, assess existing capacity and monitor services. The
refugee community should be involved in the needs assessment process
from the beginning. Refugees should participate in:
The Structure of the Field Manual
The principles that have been developed within this introduction apply to all chapters throughout the Field Manual.
Not all components of RH service provision are appropriate within the initial phases of a refugee situation. This Field Manual is intended to assist field staff in implementing such services in phases, moving from minimal to comprehensive services as the situation gradually stabilises.
In recognition of the urgency in dealing with some RH issues, Chapter Two of this Field Manual describes in detail the components of a "Minimum Initial Service Package" (MISP). It is a range of core RH activities to be carried out from the beginning of the emergency. The activities outlined within MISP should be conducted alongside other initial-phase interventions that take place in any newly identified refugee or emergency situation.
A more comprehensive package of RH interventions must then be provided as the situation stabilises. These interventions should be integrated into Primary Health Care services.
chapters of the Field Manual and the main goal of each are:
Each chapter of the Field Manual begins with an overall goal and provides detailed guidance on the elements of the RH component. These elements need to be adapted to each refugee situation in close collaboration with host-country authorities. A checklist for establishing the particular RH component is provided at the end of each chapter. This list can also be used for supervising and monitoring. Further references can also be found at the end of each chapter.
Manual does not address a number of other issues related to reproductive
health, either because they are relatively less significant in terms
of public health, or because they may be approached as in normal situations
and information on the issue is abundant elsewhere. This is the case
for most needs of post-menopausal women, elective abortion, reproductive
tract cancers and infertility.
"Declaration and Platform for Action", Fourth World Conference on Women, Beijing, 1995.
"Medical Ethics and Human Rights: Guiding Principles", Commonwealth Medical Association, London, 1997.
"Programme of Action", International Conference on Population and Development, Cairo, 1994.
"Refugee Reproductive Health Needs Assessment Field Tools", Reproductive Health for Refugees Consortium, New York, 1997.
"Refugee Women and Reproductive Health Care: Reassessing Priorities", Women's Commission for Refugee Women and Children, New York, 1994.
"Reproductive Health Services During Conflict and Displacement: Guidelines for the Design and Management of Reproductive Health Programmes" (in preparation), WHO, Geneva, 1998.
Health One and Five Day Training Packages, RHR Consortium, New York,