Wishful thinking versus operational commitment: is the international guidance on priority sexual and reproductive health interventions in humanitarian settings becoming unrealistic?

Wishful thinking versus operational commitment: is the international guidance on priority sexual... Twenty-one years ago, a global consortium of like-minded institutions designed the landmark Minimum Initial Service Package (MISP) for sexual and reproductive health (SRH) to guide national and international humanitarian first responders in preventing morbidity and mortality at the onset of chaos, destruction, and high insecurity caused by disasters or conflicts. Since then, the MISP has undergone limited change and has become an international reference in humanitarian response. This article discusses our perspectives regarding the 2018 changes to the MISP that have created division among humanitarian field practitioners, academics, advocates, and development agencies. With more than 50 pages, the new MISP chapter dilutes key guidance and messages on the most life- saving activities, leaving actors with excessive room for interpretation as to which priority activities need to be first implemented. Consequently, non-life-saving interventions may take precedence over essential ones. Insecurity, scarce human and financial resources, logistics constrains, and other limitations imposed by field reality at the onset of a crisis must be considered. We strongly recommend that an institution with the mandate, legitimacy, and technical expertise in the review of guidelines reexamines the 2018 edition of the MISP. We urge experienced first- line responders, national actors, and relevant agencies to join efforts to ensure that the MISP remains focused on a very limited set of essential activities and supplies that are pragmatic, field-oriented, and, most importantly, immediately life-saving for people in need. Background established the Inter-Agency Working Group (IAWG) In the face of the massive scale of sexual violence during for Reproductive Health in Crises. In 1996, the IAWG the Rwandan genocide and its aftermath, and following designed the Minimum Initial Service Package (MISP) the 1994 International Conference on Population and for SRH to guide first responders in emergencies in pre- Development (ICPD) in Cairo, which enshrined access venting SRH-related morbidity and mortality. The MISP to sexual and reproductive health (SRH) for refugees pursues five objectives, each objective with its specific and internally displaced populations, the Inter-Agency activities, to be implemented as a priority at the onset of Symposium on Reproductive Health in Refugee Situa- a humanitarian response to an emergency. Two objec- tions gathered UN agencies, NGOs, donors, and aca- tives focus on coordination and planning (ensuring the demic institutions in Geneva in 1995. This consortium health sector/cluster identifies an organization to lead implementation of the MISP; planning for comprehen- * Correspondence: nguyen-toan.tran@unige.ch sive SRH services, integrated into primary health care as Australian Centre for Public and Population Health Research, Faculty of soon as possible) and three objectives address the Health, University of Technology, PO Box 123, Sydney, NSW 2007, Australia provision of SRH services that aim to save lives or allevi- Institute of Demography and Socioeconomics (IDESO), University of Geneva, 40 bd Pont d’Arve, 1211 Genève 4, Switzerland ate diseases and suffering during the initial phase of an Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tran and Schulte-Hillen Conflict and Health (2018) 12:32 Page 2 of 5 emergency (prevent sexual violence and respond to the recommend that the currently finalized MISP guidance needs of survivors; prevent the transmission of and re- be reexamined by an institution with the mandate, legit- duce morbidity and mortality due to HIV and other imacy, and technical excellence in guideline review. The sexually transmitted infections; prevent excess maternal process should not only be based on scientific evidence, and newborn morbidity and mortality). but also on acceptability and pragmatic considerations The MISP is outlined in the Inter-Agency Field Manual in the field. It must therefore involve relevant national (IAFM) on Reproductive Health in Humanitarian Settings, stakeholders along with international actors. To further which was first published in 1999. Over the past 20 years, legitimize the revision process vis-à-vis national stake- the MISP has become a minimum standard in humanitar- holders and humanitarian partners, the World Health ian response and its objectives and related activities Organization (WHO) must be engaged, as well as the underwent technical updates and some modification and United Nations High Commissioner for Refugees wording change aimed at improving its clarity during the (UNHCR) and the United Nations Population Fund IAFM revision in 2010. (UNFPA). UNHCR and UNFPA directly coordinate with local authorities and partners to ensure that the MISP is An inadequate revision process implemented in humanitarian settings. The final deci- The IAWG undertook another revision of the IAFM sion on the 2018 and future revisions of the MISP guid- over the 2016–2017 period, involving “a deliberate col- ance must be the responsibility of experts and laborative process that included hundreds of individuals experienced field implementers who have direct ac- from dozens of agencies and organizations working in countability for emergency medical interventions. There- humanitarian settings at global, regional, and local levels. fore, we feel compelled to reiterate our concerns vis-à- The updates to the IAFM…represent the consensus vis the revision process and some of the changes in the positions of a wide cross-section of agencies working on MISP, which is the cornerstone of the IAFM, as they sexual and reproductive health in the humanitarian may fail to ensure the most basic medical care required sector” [1]. by women and girls at the onset of an emergency. We fully acknowledge the efforts made to raise and debate the new options for the MISP in the IAFM revi- “Mist in the MISP” sion. The adopted revision process was very lengthy During its 16th annual meeting which took place in because it aimed to be inclusive of the growing number March 2016, the IAWG, which carried out a global of IAWG partners (many of them North American) and evaluation of its work since 2004, took stock of advances the diversity of views, including those of advocates, in, and remaining challenges for SRH in humanitarian academics, development institutions, and a minority of settings [2]: as a result of the IAWG partners’ efforts, humanitarian agencies. It did not favor the participation the MISP had become a well-known and widely applied and the voices of the more pragmatic and field-oriented reference for action in humanitarian settings; an in- humanitarian actors – there were no national actors in- creased number of institutions provided MISP-related volved in humanitarian preparedness and response in and comprehensive SRH services; the availability of their countries. When it comes to setting standards, it is abortion-related services and the provision of long- critical to take stock of more than 20 years of experience acting and reversible contraceptive methods were found in MISP implementation. Most of the proposed changes to be lagging; only a third of institutions working in the (see examples below) were pushed through by IAWG field reported appointing an SRH coordinator; and plan- sub-working groups with their own single-issue priorities ning for comprehensive SRH remained often misunder- on abortion, contraception or rights advocacy, without stood or challenging to implement. Given the diverse much consideration of MISP implementation challenges nature of humanitarian crises, some IAWG members and its objectives as a whole. have argued that the MISP is not adapted to different The responsibility of altering the MISP should be col- settings or to current emergencies. Other members have laborative but not dependent on a democratic voting advocated for stronger emphasis on services that were process among IAWG members that creates a bias to- found to be weak in the 2014 Global Evaluation, such as wards the opinion of advocacy, rights-based, academic contraception or abortion care. This led to different or other institutions that have no experience or first-line ideas and discussions to complement the MISP with responsibilities in the acute phase of a humanitarian additional objectives and activities to form a “MISP+” response: in the end, they are not the agencies setting up set of interventions. In 2016, we pointed to the fact that services nor is their staff living with the day-to-day there was still “mist in the MISP” and how proposed trade-offs between limited resources, protecting rights, changes to the MISP hinge on the lack of understanding and deciding what can be done amidst chaos, insecurity, of (i) the purpose of the MISP (priority life-saving SRH and political uncertainty. Therefore, we strongly interventions that can be implemented during the chaotic Tran and Schulte-Hillen Conflict and Health (2018) 12:32 Page 3 of 5 first days of a humanitarian response without an in-depth Compromising the implementation of the MISP SRH needs assessment), (ii) the often very limited oper- The MISP must remain field-oriented and pragmatic ational and technical capacity of national and international The MISP is designed to be implemented amid chaos actors, and (iii) two crucial, interconnected MISP objec- and high insecurity when the health system has been se- tives: (1) planning for comprehensive SRH, which in turns verely impaired, including staff, logistics, infrastructure, depends on (2) the (too-rarely-done) systematic appoint- and health information systems. In such a setting, there ment of an effective SRH coordinator whose role it is to is no time for capacity development of staff, no time for manage MISP implementation and the transition towards in-depth needs assessment, no time for public health comprehensive SRH once the situation has stabilized. campaigns, comprehensive services, and polished quality Therefore, we recommended to leave the MISP guidance of care, all of which are part of the planning for context- as such intact and to focus efforts on developing the cap- appropriate comprehensive services once the situation acity of IAWG institutions in terms of operational and has stabilized. Therefore, the MISP must remain field- technical capacity and on the management and leadership oriented and pragmatic. With more than 50 pages long, objectives of the MISP: SRH coordination and planning the new IAFM chapter on the MISP dilutes key guidance for comprehensive SRH. Nevertheless, the IAFM revision and messages regarding the most essential life-saving process adopted changes that we believe will contribute to activities, with certain activities containing many details compromise the implementation of immediately life- (e.g., prescribing emergency contraceptive pills, provid- saving MISP services by diverting resources and attention ing newborn health care), while others have few, such as to other activities. For example: emergency obstetric care – the most life-saving maternal First, addition of a new objective and related activities and newborn health (MNH) interventions. This leaves on contraception: (Objective:) “prevent unintended preg- actors with excessive room for interpretation as to which nancies” by (Activity 1:) “ensuring availability of a range priority activities should be implemented, supported, co- of long-acting reversible and short-acting contraceptive ordinated and funded. Consequently, activities that are methods (including male and female condoms and not immediately life-saving may take precedence over emergency contraception) at primary health care facil- essential ones. Two examples: ities to meet demand”; by (Activity 2:) “providing infor- First, there should not be a sixth objective - preventing mation, including information, education, and unintended pregnancies. Although currently a global communication (IEC) materials, and, as soon as possible, focus of FP2020 and other planetary health initiatives, ensuring contraceptive counseling that emphasizes in- preventing unintended pregnancies through contracep- formed choice, effectiveness, and supports client privacy tion remains a cornerstone of MNH along with EmONC and confidentiality”; and by (Activity 3:) “ensuring the and should therefore be subsumed under the already community is aware of the availability of contraceptives existing MNH objective. There is no time, especially for women, adolescents, and men.” Activity 3 has two when EmONC services are not yet set up, to start com- sub-activities: (Sub-activity 3.1:) “Ensure the community prehensive contraceptive programming at the onset of is aware of where and how to seek access to contracep- an emergency, “to engage community leaders…” or de- tion, including unmarried and adolescent community sign and provide IEC materials “in multiple formats and members. Information should be communicated in mul- languages to ensure accessibility (e.g., Braille,…).” In tiple formats and languages to ensure accessibility (e.g., addition, “counseling that emphasizes informed choice, Braille, sign language, pictograms and pictures)”; (Sub- effectiveness, and supports client privacy and confidenti- activity 3.2:) “Engage community leaders to disseminate ality” are crosscutting rights-based quality of care musts, information about availability of contraceptive services.” which have been advocated for by WHO but are not In the 2010 version of the MISP, the recommended ac- restricted to contraceptive services: it applies to all SRH tivity was succinctly put: “provide contraceptives, such and health services [3]. Therefore, it should be moved as condoms, pills, injectables, and intra-uterine devices out from these activities and integrated into the overall (IUD) to meet demand” and commonly appended to the quality of care objectives ensured by SRH providers, objective “prevent excess maternal and neonatal morbid- managers, and coordinators. ity and mortality.” Second, to the objectives, a “note”, Second, all affected populations, including subgroups, which is actually an additional priority, is added: “It is such as people living with disability, adolescents, older also important to ensure that safe abortion care is avail- people, sex workers, or members of the lesbian, gay, bisex- able, to the full extent of the law, in health centers and ual, transgender, queer/questioning, intersex, and asexual hospital facilities.” In the original version of the MISP, community, among others, should have access to life- uterine evacuation is embedded as one of the signal saving SRH services. Non-discrimination, safety, respect, functions needed to “ensure the availability of Emergency and confidentiality are already embedded in the overarch- Obstetrics and Newborn Care (EmONC).” ing values necessary to the MISP implementation. The Tran and Schulte-Hillen Conflict and Health (2018) 12:32 Page 4 of 5 new MISP chapter expands on subgroups and proposes methods should be introduced as part of the design of targeted activities, such as engagement with these quality comprehensive SRH services. communities and training providers on their specific needs. Such activities, to be meaningful and of high Human rights in the face of insecurity and realpolitik quality, cannot be done in a “touch-and-go” fashion The right to medical care is a human right which applies amid chaos and insecurity and require in-depth needs to access to safe abortion care (SAC). Institutional and assessment and planning with the populations of concern. staff resistance and lack of capacity to provide SAC are Therefore, this should not be part of MISP, but needs to widespread in stable contexts and even in contexts be an essential part of planning for comprehensive pro- where it is legal. Why aid organizations are not provid- gramming and emergency preparedness plans. ing SAC to avert one of the main causes of maternal deaths and suffering has been debated at length. This in- cludes insights into the vast field experience of MSF and The implementation of the MISP is constrained by the enormous amount of investment and training logistics needed to just even scratch the surface of the issue in At the onset of disasters, like the tsunami in 2004, the field operations, among staff, and within the affected earthquake in Haiti in 2011 or in Nepal in 2015, or in communities [5], and was demonstrated by the presenta- war-torn situations such as Yemen or South Sudan, tions on SAC programs during the recent 2017 IAWG ensuring availability of life-saving supplies presents a annual meeting (none presented a SAC program during colossal challenge. The choice of supplies that need to an acute phase response and all of the presenters agreed be financed, transported - and stored - should be in- that this would be very difficult). Amid chaos and inse- formed by the MISP activities and be obvious to field curity, openly focusing on such a sensitive issue may put actors. Within the supply chain, adding a non-essential field staff, patients, and operations at risk. Making SAC supply is a trade-off for another essential one. The MISP visibly upfront in the MISP – even as a “note” and not should therefore remain focused on a very limited set of as an “objective”– is commendable but will render the essential activities and related supplies for the initial work of implementing agencies problematic. Host gov- response. ernments and local authorities, to avoid conflict with na- The proposition to add lubricants and female con- tional legislations, may be reluctant to conclude working doms to the activity to ensure condom availability – agreements with IAWG-signatory organizations, thus eventually removed from the final version - exempli- potentially delaying the operational set-up and paralyz- fies how some of the proposed recommendations ing the implementation of other MISP activities and as- departed from logistics and field realities. Female sistance to people in need because of this single issue. condoms should only be made available during the For example, in the aftermath of the 2008 cyclone Nargis emergency response if pre-existing demand is known, in Myanmar, local authorities forbid the custom clear- otherwise they will go to waste. WHO recommends ance of inter-agency SRH kits because of kit 8, which lubricants for MSM and sex worker programs, how- was then named “management of abortion complica- ever with different specificities for anal sex and vaginal tions.” Kit 8, which contains manual vacuum aspiration sex [4]. Inaddition,somelubricants mayincreasethe and misoprostol, is necessary to perform uterine evacu- risk of epithelial damage and must be carefully chosen ation (one of the seven EmONC signal functions). To [4]. Finally, the condoms in the inter-agency SRH kits avoid repetition in the future, kit 8 is now re-named that support the implementation of the MISP are without the “abortion” word: to “manage the complica- already lubricated and including additional lubricants tions of miscarriages.” This practical example illustrates will not only increase significantly the price of ship- how the crafting of the MISP is best informed by field ping by air but will be done at the expense of other practice and reality – as well as realpolitik. life-saving supplies – such trade-off choices should not exist in an emergency. Likewise, a focus on mak- Conclusions ing long-acting reversible contraceptives systematic- The success of the IAWG is largely due to its openness ally available within a range of methods in all settings and inclusiveness towards a large and growing range of should take into consideration the risk of IUDs or im- institutions working on SRH. Many of these institutions plants going to waste if they were not known and used pursue diverse agendas, including advocacy, human by the affected communities prior to the crisis. In rights, development, and research. Using the MISP as an addition, women who receive IUDs and implants in advocacy vehicle to defend with fervor and pride com- acute humanitarian context may not have access prehensive contraception services and SAC has oversha- during their forced displacement to counseling on dowed the unmet need for early transition from MISP to side-effects and contraceptive removal services. Such comprehensive SRH services. This has raised doubts to Tran and Schulte-Hillen Conflict and Health (2018) 12:32 Page 5 of 5 what extent the various actors have a shared under- Received: 1 March 2018 Accepted: 28 March 2018 standing of impartiality in humanitarian crisis settings. The revision process of an operational guidance docu- References ment, which may be enriched by different viewpoints, 1. Foster AM, Evans DP, Garcia M, Knaster S, Krause S, McGinn T, et al. The 2018 Inter-agency field manual on reproductive health in humanitarian settings: needs to respond first and foremost to the challenges revising the global standards. Reprod Health Matters. 2017;25(51):18–24. encountered by field actors, and be led by an institution 2. Chynoweth SK. Advancing reproductive health on the humanitarian that has the mandate, expertise, and legitimacy to do so. agenda: the 2012–2014 global review. Confl Heal. 2015;9(1):I1. 3. World Health Organization. Framework for ensuring human rights in the In addition to coordination and early planning for provision of contraceptive information and services. 2014. context-appropriate quality comprehensive SRH ser- 4. World Health Organization. Use and procurement of additional lubricants vices, the MISP needs to remain a relevant must among for male and female condoms. 2012. 5. Schulte-Hillen C, Staderini N, Saint-Sauveur J-F. Why Médecins Sans donors and humanitarian responders in times of scarce Frontières (MSF) provides safe abortion care and what that involves. Confl resources and limited capacity. It must focus on a very Heal. 2016;10(1):19. limited set of essential activities and supplies that are pragmatic, field-oriented, and, most importantly, imme- diately life-saving for people in need. Abbreviations EmONC: Emergency Obstetrics and Newborn Care; IAFM: Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings; IAWG: Inter- Agency Working Group for Reproductive Health in Crises; IEC: Information, education, and communication; IUD: Intra-uterine device; MISP: Minimum Initial Service Package for sexual and reproductive health in crises; MNH: Maternal and newborn health; SAC: Safe abortion care; SRH: Sexual and reproductive health; UNFPA: United Nations Population Fund; UNHCR: United Nations High Commissioner for Refugees; WHO: World Health Organization Acknowledgements The authors would like to thank the following experts in SRH in humanitarian settings for their meaningful analysis and insights with regard to the revision of the MISP: Dr. Wilma Doedens from UNFPA and Dr. Josep Vargas and Dr. Ann Burton from UNHCR. Funding Not applicable. Availability of data and materials Not applicable. Authors’ contributions CSH and NTT conceptualized the main arguments of the paper. NTT wrote the manuscript with the contributions of CSH. All authors read and approved the final manuscript. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. 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Wishful thinking versus operational commitment: is the international guidance on priority sexual and reproductive health interventions in humanitarian settings becoming unrealistic?

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Abstract

Twenty-one years ago, a global consortium of like-minded institutions designed the landmark Minimum Initial Service Package (MISP) for sexual and reproductive health (SRH) to guide national and international humanitarian first responders in preventing morbidity and mortality at the onset of chaos, destruction, and high insecurity caused by disasters or conflicts. Since then, the MISP has undergone limited change and has become an international reference in humanitarian response. This article discusses our perspectives regarding the 2018 changes to the MISP that have created division among humanitarian field practitioners, academics, advocates, and development agencies. With more than 50 pages, the new MISP chapter dilutes key guidance and messages on the most life- saving activities, leaving actors with excessive room for interpretation as to which priority activities need to be first implemented. Consequently, non-life-saving interventions may take precedence over essential ones. Insecurity, scarce human and financial resources, logistics constrains, and other limitations imposed by field reality at the onset of a crisis must be considered. We strongly recommend that an institution with the mandate, legitimacy, and technical expertise in the review of guidelines reexamines the 2018 edition of the MISP. We urge experienced first- line responders, national actors, and relevant agencies to join efforts to ensure that the MISP remains focused on a very limited set of essential activities and supplies that are pragmatic, field-oriented, and, most importantly, immediately life-saving for people in need. Background established the Inter-Agency Working Group (IAWG) In the face of the massive scale of sexual violence during for Reproductive Health in Crises. In 1996, the IAWG the Rwandan genocide and its aftermath, and following designed the Minimum Initial Service Package (MISP) the 1994 International Conference on Population and for SRH to guide first responders in emergencies in pre- Development (ICPD) in Cairo, which enshrined access venting SRH-related morbidity and mortality. The MISP to sexual and reproductive health (SRH) for refugees pursues five objectives, each objective with its specific and internally displaced populations, the Inter-Agency activities, to be implemented as a priority at the onset of Symposium on Reproductive Health in Refugee Situa- a humanitarian response to an emergency. Two objec- tions gathered UN agencies, NGOs, donors, and aca- tives focus on coordination and planning (ensuring the demic institutions in Geneva in 1995. This consortium health sector/cluster identifies an organization to lead implementation of the MISP; planning for comprehen- * Correspondence: nguyen-toan.tran@unige.ch sive SRH services, integrated into primary health care as Australian Centre for Public and Population Health Research, Faculty of soon as possible) and three objectives address the Health, University of Technology, PO Box 123, Sydney, NSW 2007, Australia provision of SRH services that aim to save lives or allevi- Institute of Demography and Socioeconomics (IDESO), University of Geneva, 40 bd Pont d’Arve, 1211 Genève 4, Switzerland ate diseases and suffering during the initial phase of an Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tran and Schulte-Hillen Conflict and Health (2018) 12:32 Page 2 of 5 emergency (prevent sexual violence and respond to the recommend that the currently finalized MISP guidance needs of survivors; prevent the transmission of and re- be reexamined by an institution with the mandate, legit- duce morbidity and mortality due to HIV and other imacy, and technical excellence in guideline review. The sexually transmitted infections; prevent excess maternal process should not only be based on scientific evidence, and newborn morbidity and mortality). but also on acceptability and pragmatic considerations The MISP is outlined in the Inter-Agency Field Manual in the field. It must therefore involve relevant national (IAFM) on Reproductive Health in Humanitarian Settings, stakeholders along with international actors. To further which was first published in 1999. Over the past 20 years, legitimize the revision process vis-à-vis national stake- the MISP has become a minimum standard in humanitar- holders and humanitarian partners, the World Health ian response and its objectives and related activities Organization (WHO) must be engaged, as well as the underwent technical updates and some modification and United Nations High Commissioner for Refugees wording change aimed at improving its clarity during the (UNHCR) and the United Nations Population Fund IAFM revision in 2010. (UNFPA). UNHCR and UNFPA directly coordinate with local authorities and partners to ensure that the MISP is An inadequate revision process implemented in humanitarian settings. The final deci- The IAWG undertook another revision of the IAFM sion on the 2018 and future revisions of the MISP guid- over the 2016–2017 period, involving “a deliberate col- ance must be the responsibility of experts and laborative process that included hundreds of individuals experienced field implementers who have direct ac- from dozens of agencies and organizations working in countability for emergency medical interventions. There- humanitarian settings at global, regional, and local levels. fore, we feel compelled to reiterate our concerns vis-à- The updates to the IAFM…represent the consensus vis the revision process and some of the changes in the positions of a wide cross-section of agencies working on MISP, which is the cornerstone of the IAFM, as they sexual and reproductive health in the humanitarian may fail to ensure the most basic medical care required sector” [1]. by women and girls at the onset of an emergency. We fully acknowledge the efforts made to raise and debate the new options for the MISP in the IAFM revi- “Mist in the MISP” sion. The adopted revision process was very lengthy During its 16th annual meeting which took place in because it aimed to be inclusive of the growing number March 2016, the IAWG, which carried out a global of IAWG partners (many of them North American) and evaluation of its work since 2004, took stock of advances the diversity of views, including those of advocates, in, and remaining challenges for SRH in humanitarian academics, development institutions, and a minority of settings [2]: as a result of the IAWG partners’ efforts, humanitarian agencies. It did not favor the participation the MISP had become a well-known and widely applied and the voices of the more pragmatic and field-oriented reference for action in humanitarian settings; an in- humanitarian actors – there were no national actors in- creased number of institutions provided MISP-related volved in humanitarian preparedness and response in and comprehensive SRH services; the availability of their countries. When it comes to setting standards, it is abortion-related services and the provision of long- critical to take stock of more than 20 years of experience acting and reversible contraceptive methods were found in MISP implementation. Most of the proposed changes to be lagging; only a third of institutions working in the (see examples below) were pushed through by IAWG field reported appointing an SRH coordinator; and plan- sub-working groups with their own single-issue priorities ning for comprehensive SRH remained often misunder- on abortion, contraception or rights advocacy, without stood or challenging to implement. Given the diverse much consideration of MISP implementation challenges nature of humanitarian crises, some IAWG members and its objectives as a whole. have argued that the MISP is not adapted to different The responsibility of altering the MISP should be col- settings or to current emergencies. Other members have laborative but not dependent on a democratic voting advocated for stronger emphasis on services that were process among IAWG members that creates a bias to- found to be weak in the 2014 Global Evaluation, such as wards the opinion of advocacy, rights-based, academic contraception or abortion care. This led to different or other institutions that have no experience or first-line ideas and discussions to complement the MISP with responsibilities in the acute phase of a humanitarian additional objectives and activities to form a “MISP+” response: in the end, they are not the agencies setting up set of interventions. In 2016, we pointed to the fact that services nor is their staff living with the day-to-day there was still “mist in the MISP” and how proposed trade-offs between limited resources, protecting rights, changes to the MISP hinge on the lack of understanding and deciding what can be done amidst chaos, insecurity, of (i) the purpose of the MISP (priority life-saving SRH and political uncertainty. Therefore, we strongly interventions that can be implemented during the chaotic Tran and Schulte-Hillen Conflict and Health (2018) 12:32 Page 3 of 5 first days of a humanitarian response without an in-depth Compromising the implementation of the MISP SRH needs assessment), (ii) the often very limited oper- The MISP must remain field-oriented and pragmatic ational and technical capacity of national and international The MISP is designed to be implemented amid chaos actors, and (iii) two crucial, interconnected MISP objec- and high insecurity when the health system has been se- tives: (1) planning for comprehensive SRH, which in turns verely impaired, including staff, logistics, infrastructure, depends on (2) the (too-rarely-done) systematic appoint- and health information systems. In such a setting, there ment of an effective SRH coordinator whose role it is to is no time for capacity development of staff, no time for manage MISP implementation and the transition towards in-depth needs assessment, no time for public health comprehensive SRH once the situation has stabilized. campaigns, comprehensive services, and polished quality Therefore, we recommended to leave the MISP guidance of care, all of which are part of the planning for context- as such intact and to focus efforts on developing the cap- appropriate comprehensive services once the situation acity of IAWG institutions in terms of operational and has stabilized. Therefore, the MISP must remain field- technical capacity and on the management and leadership oriented and pragmatic. With more than 50 pages long, objectives of the MISP: SRH coordination and planning the new IAFM chapter on the MISP dilutes key guidance for comprehensive SRH. Nevertheless, the IAFM revision and messages regarding the most essential life-saving process adopted changes that we believe will contribute to activities, with certain activities containing many details compromise the implementation of immediately life- (e.g., prescribing emergency contraceptive pills, provid- saving MISP services by diverting resources and attention ing newborn health care), while others have few, such as to other activities. For example: emergency obstetric care – the most life-saving maternal First, addition of a new objective and related activities and newborn health (MNH) interventions. This leaves on contraception: (Objective:) “prevent unintended preg- actors with excessive room for interpretation as to which nancies” by (Activity 1:) “ensuring availability of a range priority activities should be implemented, supported, co- of long-acting reversible and short-acting contraceptive ordinated and funded. Consequently, activities that are methods (including male and female condoms and not immediately life-saving may take precedence over emergency contraception) at primary health care facil- essential ones. Two examples: ities to meet demand”; by (Activity 2:) “providing infor- First, there should not be a sixth objective - preventing mation, including information, education, and unintended pregnancies. Although currently a global communication (IEC) materials, and, as soon as possible, focus of FP2020 and other planetary health initiatives, ensuring contraceptive counseling that emphasizes in- preventing unintended pregnancies through contracep- formed choice, effectiveness, and supports client privacy tion remains a cornerstone of MNH along with EmONC and confidentiality”; and by (Activity 3:) “ensuring the and should therefore be subsumed under the already community is aware of the availability of contraceptives existing MNH objective. There is no time, especially for women, adolescents, and men.” Activity 3 has two when EmONC services are not yet set up, to start com- sub-activities: (Sub-activity 3.1:) “Ensure the community prehensive contraceptive programming at the onset of is aware of where and how to seek access to contracep- an emergency, “to engage community leaders…” or de- tion, including unmarried and adolescent community sign and provide IEC materials “in multiple formats and members. Information should be communicated in mul- languages to ensure accessibility (e.g., Braille,…).” In tiple formats and languages to ensure accessibility (e.g., addition, “counseling that emphasizes informed choice, Braille, sign language, pictograms and pictures)”; (Sub- effectiveness, and supports client privacy and confidenti- activity 3.2:) “Engage community leaders to disseminate ality” are crosscutting rights-based quality of care musts, information about availability of contraceptive services.” which have been advocated for by WHO but are not In the 2010 version of the MISP, the recommended ac- restricted to contraceptive services: it applies to all SRH tivity was succinctly put: “provide contraceptives, such and health services [3]. Therefore, it should be moved as condoms, pills, injectables, and intra-uterine devices out from these activities and integrated into the overall (IUD) to meet demand” and commonly appended to the quality of care objectives ensured by SRH providers, objective “prevent excess maternal and neonatal morbid- managers, and coordinators. ity and mortality.” Second, to the objectives, a “note”, Second, all affected populations, including subgroups, which is actually an additional priority, is added: “It is such as people living with disability, adolescents, older also important to ensure that safe abortion care is avail- people, sex workers, or members of the lesbian, gay, bisex- able, to the full extent of the law, in health centers and ual, transgender, queer/questioning, intersex, and asexual hospital facilities.” In the original version of the MISP, community, among others, should have access to life- uterine evacuation is embedded as one of the signal saving SRH services. Non-discrimination, safety, respect, functions needed to “ensure the availability of Emergency and confidentiality are already embedded in the overarch- Obstetrics and Newborn Care (EmONC).” ing values necessary to the MISP implementation. The Tran and Schulte-Hillen Conflict and Health (2018) 12:32 Page 4 of 5 new MISP chapter expands on subgroups and proposes methods should be introduced as part of the design of targeted activities, such as engagement with these quality comprehensive SRH services. communities and training providers on their specific needs. Such activities, to be meaningful and of high Human rights in the face of insecurity and realpolitik quality, cannot be done in a “touch-and-go” fashion The right to medical care is a human right which applies amid chaos and insecurity and require in-depth needs to access to safe abortion care (SAC). Institutional and assessment and planning with the populations of concern. staff resistance and lack of capacity to provide SAC are Therefore, this should not be part of MISP, but needs to widespread in stable contexts and even in contexts be an essential part of planning for comprehensive pro- where it is legal. Why aid organizations are not provid- gramming and emergency preparedness plans. ing SAC to avert one of the main causes of maternal deaths and suffering has been debated at length. This in- cludes insights into the vast field experience of MSF and The implementation of the MISP is constrained by the enormous amount of investment and training logistics needed to just even scratch the surface of the issue in At the onset of disasters, like the tsunami in 2004, the field operations, among staff, and within the affected earthquake in Haiti in 2011 or in Nepal in 2015, or in communities [5], and was demonstrated by the presenta- war-torn situations such as Yemen or South Sudan, tions on SAC programs during the recent 2017 IAWG ensuring availability of life-saving supplies presents a annual meeting (none presented a SAC program during colossal challenge. The choice of supplies that need to an acute phase response and all of the presenters agreed be financed, transported - and stored - should be in- that this would be very difficult). Amid chaos and inse- formed by the MISP activities and be obvious to field curity, openly focusing on such a sensitive issue may put actors. Within the supply chain, adding a non-essential field staff, patients, and operations at risk. Making SAC supply is a trade-off for another essential one. The MISP visibly upfront in the MISP – even as a “note” and not should therefore remain focused on a very limited set of as an “objective”– is commendable but will render the essential activities and related supplies for the initial work of implementing agencies problematic. Host gov- response. ernments and local authorities, to avoid conflict with na- The proposition to add lubricants and female con- tional legislations, may be reluctant to conclude working doms to the activity to ensure condom availability – agreements with IAWG-signatory organizations, thus eventually removed from the final version - exempli- potentially delaying the operational set-up and paralyz- fies how some of the proposed recommendations ing the implementation of other MISP activities and as- departed from logistics and field realities. Female sistance to people in need because of this single issue. condoms should only be made available during the For example, in the aftermath of the 2008 cyclone Nargis emergency response if pre-existing demand is known, in Myanmar, local authorities forbid the custom clear- otherwise they will go to waste. WHO recommends ance of inter-agency SRH kits because of kit 8, which lubricants for MSM and sex worker programs, how- was then named “management of abortion complica- ever with different specificities for anal sex and vaginal tions.” Kit 8, which contains manual vacuum aspiration sex [4]. Inaddition,somelubricants mayincreasethe and misoprostol, is necessary to perform uterine evacu- risk of epithelial damage and must be carefully chosen ation (one of the seven EmONC signal functions). To [4]. Finally, the condoms in the inter-agency SRH kits avoid repetition in the future, kit 8 is now re-named that support the implementation of the MISP are without the “abortion” word: to “manage the complica- already lubricated and including additional lubricants tions of miscarriages.” This practical example illustrates will not only increase significantly the price of ship- how the crafting of the MISP is best informed by field ping by air but will be done at the expense of other practice and reality – as well as realpolitik. life-saving supplies – such trade-off choices should not exist in an emergency. Likewise, a focus on mak- Conclusions ing long-acting reversible contraceptives systematic- The success of the IAWG is largely due to its openness ally available within a range of methods in all settings and inclusiveness towards a large and growing range of should take into consideration the risk of IUDs or im- institutions working on SRH. Many of these institutions plants going to waste if they were not known and used pursue diverse agendas, including advocacy, human by the affected communities prior to the crisis. In rights, development, and research. Using the MISP as an addition, women who receive IUDs and implants in advocacy vehicle to defend with fervor and pride com- acute humanitarian context may not have access prehensive contraception services and SAC has oversha- during their forced displacement to counseling on dowed the unmet need for early transition from MISP to side-effects and contraceptive removal services. Such comprehensive SRH services. This has raised doubts to Tran and Schulte-Hillen Conflict and Health (2018) 12:32 Page 5 of 5 what extent the various actors have a shared under- Received: 1 March 2018 Accepted: 28 March 2018 standing of impartiality in humanitarian crisis settings. The revision process of an operational guidance docu- References ment, which may be enriched by different viewpoints, 1. Foster AM, Evans DP, Garcia M, Knaster S, Krause S, McGinn T, et al. The 2018 Inter-agency field manual on reproductive health in humanitarian settings: needs to respond first and foremost to the challenges revising the global standards. Reprod Health Matters. 2017;25(51):18–24. encountered by field actors, and be led by an institution 2. Chynoweth SK. Advancing reproductive health on the humanitarian that has the mandate, expertise, and legitimacy to do so. agenda: the 2012–2014 global review. Confl Heal. 2015;9(1):I1. 3. World Health Organization. Framework for ensuring human rights in the In addition to coordination and early planning for provision of contraceptive information and services. 2014. context-appropriate quality comprehensive SRH ser- 4. World Health Organization. Use and procurement of additional lubricants vices, the MISP needs to remain a relevant must among for male and female condoms. 2012. 5. Schulte-Hillen C, Staderini N, Saint-Sauveur J-F. Why Médecins Sans donors and humanitarian responders in times of scarce Frontières (MSF) provides safe abortion care and what that involves. Confl resources and limited capacity. It must focus on a very Heal. 2016;10(1):19. limited set of essential activities and supplies that are pragmatic, field-oriented, and, most importantly, imme- diately life-saving for people in need. Abbreviations EmONC: Emergency Obstetrics and Newborn Care; IAFM: Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings; IAWG: Inter- Agency Working Group for Reproductive Health in Crises; IEC: Information, education, and communication; IUD: Intra-uterine device; MISP: Minimum Initial Service Package for sexual and reproductive health in crises; MNH: Maternal and newborn health; SAC: Safe abortion care; SRH: Sexual and reproductive health; UNFPA: United Nations Population Fund; UNHCR: United Nations High Commissioner for Refugees; WHO: World Health Organization Acknowledgements The authors would like to thank the following experts in SRH in humanitarian settings for their meaningful analysis and insights with regard to the revision of the MISP: Dr. Wilma Doedens from UNFPA and Dr. Josep Vargas and Dr. Ann Burton from UNHCR. Funding Not applicable. Availability of data and materials Not applicable. Authors’ contributions CSH and NTT conceptualized the main arguments of the paper. NTT wrote the manuscript with the contributions of CSH. All authors read and approved the final manuscript. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Submit your next manuscript to BioMed Central Competing interests The authors declare that they have no competing interests. and we will help you at every step: • We accept pre-submission inquiries Publisher’sNote � Our selector tool helps you to find the most relevant journal Springer Nature remains neutral with regard to jurisdictional claims in � We provide round the clock customer support published maps and institutional affiliations. � Convenient online submission Author details � Thorough peer review Australian Centre for Public and Population Health Research, Faculty of � Inclusion in PubMed and all major indexing services Health, University of Technology, PO Box 123, Sydney, NSW 2007, Australia. � Maximum visibility for your research Institute of Demography and Socioeconomics (IDESO), University of Geneva, 40 bd Pont d’Arve, 1211 Genève 4, Switzerland. Médecins sans Frontières, Submit your manuscript at Rue de Lausanne 78, 1202 Genève, Switzerland. www.biomedcentral.com/submit

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Conflict and HealthSpringer Journals

Published: May 29, 2018

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