of the MISP
qualified and experienced person should be identified to coordinate
RH activities at the start of the emergency response. The overall leading
agency should be responsible for the designation of such a person, and
the person appointed should work under the supervision of the overall
focal points should be designated within each camp, and within each
implementing agency. These health professionals, experienced in reproductive
health, should be in post for a minimum of six months, as it is likely
to take this long to establish comprehensive RH services.
relief organisations should, in accordance with their mandates, and
within the framework of emergency preparedness and response, train and
sensitise their staff on RH issues and gender awareness. (See Terms of Reference for the RH Coordinator at the
end of this chapter.)
violence is strongly associated with situations of forced population
movement. In this context, it is vital that all actors in the emergency
response are aware of this issue and preventive measures are put in
place. The UNHCR Guidelines for Prevention and Response to Sexual Violence
against Refugees (1995) should be adhered to in the emergency response.
Measures for assisting refugees who have experienced sexual violence,
including rape, must also be established in the early phase of an emergency.
who have experienced sexual violence should be referred to the health
services as soon as possible after the incident. Protection staff should
also be involved in providing protection and legal support to survivors
of sexual violence.
actions to be taken during the emergency to reduce the risk of sexual
violence and respond to survivors are:
and locate refugee camps, in consultation with refugees, to enhance
the presence of female protection and health staff and interpreters
the issues of sexual violence in the health coordination meetings
refugees are informed of the availability of services for survivors
of sexual violence
a medical response to survivors of sexual violence, including emergency
contraception, as appropriate
individual or groups who may be particularly at risk to sexual violence
(single female heads-of-households, unaccompanied minors, etc.)
and address their protection and assistance needs.
Chapter Four for further information on elements of prevention
and response to sexual violence.
Respect for Universal Precautions Against HIV/AIDS
Universal precautions against the spread of HIV/ AIDS within the health
care setting must be emphasised during the first meeting of Health Coordinators.
Under the pressure of an emergency situation, it is possible that field
staff are tempted to take short cuts in procedures which can jeopardise
the safety of patients and staff. It is essential that universal precautions
be respected. (See Chapter Five for details on universal precautions.)
the Availability of Free Condoms
Availability of condoms should be ensured from the beginning so that
they can be provided to anyone who requests them. Sufficient supplies
should be ordered immediately. (See Annex 3, Chapter Five, Prevention and Care of Sexually
Transmitted Diseases including HIV and AIDS for calculating condom supplies.)
well as providing condoms on request, field staff should make sure that
refugees are aware that condoms are available and where they can be
obtained. Condoms should be made available in health facilities especially
when treating cases of STDs. Other distribution points should be established
so that those requesting condoms can obtain them in privacy.
Clean Delivery Kits for Use by Mothers or Birth Attendants to Promote
Clean Home Deliveries
A refugee population will include women who are in the later stages
of pregnancy, and who will therefore deliver within the initial phase.
Simple delivery kits for home use should be made available for women
in the late stages of pregnancy. These are very simple kits that the
women, themselves, or traditional birth attendants (TBAs) can use. They
can be made up on site and include: one sheet of plastic, two pieces
of string, one clean razor blade and one bar of soap. UNFPA also supplies
formula, based upon the Crude Birth Rate (CBR), is used to calculate
the supplies and services required. With a CBR of three to five per
cent per year, there would be some 75-125 births in a three-month period
in a population of 10,000. From this, a calculation can be made as to
how many kits should be ordered.
Midwife Delivery Kits (UNICEF or equivalent) to Facilitate Clean and
Safe Deliveries at the Health Facility
In the early phase of an emergency, births will often take place outside
the health facility without the assistance of trained health personnel.
Approximately 15 per cent of births will involve some complications.
Complicated births should be referred to the health centre. The supplementary
unit of the New Emergency Health Kit 98 (NEHK-98) has all the materials
needed to ensure safe and clean normal deliveries. Many obstetric emergencies
can be managed with the equipment, supplies and drugs contained in the
NEHK-98. Obstetric complications that cannot be managed at the health
centre should be stabilised before transfer to the referral hospital.
the Establishment of a Referral System to Manage Obstetric Emergencies
Approximately three to seven per cent of deliveries will require Caesarean
section. Additional obstetric emergencies may need to be referred to
a hospital that is capable of performing comprehensive essential emergency
obstetric care. (Refer to Chapters Three and Seven for information on pregnancy and delivery complications.)
soon as the situation permits, a referral system that manages obstetric
complications must be available for use by the refugee population 24
hours a day. Where feasible, a host-country referral facility should
be used and supported to meet the needs of refugees. If this is not
feasible because of distance or the inability of the host-country facility
to meet the increased demand, then an appropriate refugee-specific referral
facility should be provided. In either case, it will be necessary to
coordinate with host-country authorities concerning the policies, procedures
and practices to be followed within the referral facility. The protocols
of the host country should be followed, although some variation may
have to be negotiated. Be sure there is sufficient transport, qualified
staff and materials to cope with the extra demands.
is essential to plan for the integration of RH activities into primary
health care during the initial phase. If not, the provision of these
services may be delayed unnecessarily. When planning, it is important
to include the following activities:
collection of background information on maternal, infant and child
mortality, available HIV/ STD prevalence and contraceptive prevalence
rates (CPR). This information can be obtained from the refugees'
country of origin from such sources as WHO, UNFPA, the World Bank
and Demographic and Health Survey (DHS). Gathering this information
could be the responsibility of the Headquarters of implementing
agencies who may have ready access to these data.
identification of suitable sites for the future delivery of comprehensive
RH services (as described in the remainder of this Field Manual).
It is important to address the following factors when selecting
both at the point of use and while moving between home and the
service delivery point
for all potential users
and confidentiality during consultations
access to water and sanitation facilities
assessment of the capacity of staff to undertake comprehensive RH
services should be made and plans put in place to train/ retrain
staff. Equipment and supplies for comprehensive RH services should
be ordered. This will allow comprehensive services to begin as soon
as the situation stabilises.
Terms of Reference for a RH Coordinator/ Focal Point
the auspices of the overall health coordination framework, the RH Coordinator/
Focal Point should
the focal point for RH services and provide technical advice and
assistance on reproductive health to refugees and all organisations
working in health and other sectors as needed.
with national and regional authorities of the host country when
planning and implementing RH activities in refugee camps and among
the surrounding population, where appropriate.
with other sectors (protection, community services, camp management,
education, etc.) to ensure a multi-sectoral approach to reproductive
and introduce standardised strategies for reproductive health which
are fully integrated within PHC.
and coordinate various audience-specific training sessions on reproductive
health (for audiences such as health workers, community services
officers, the refugee population, security personnel, etc.).
standardised protocols for selected areas (such as syndromic case
management of STDs, referral of obstetric emergencies, medical response
to survivors of sexual violence, counselling and family planning
adapt and introduce simple forms for monitoring RH activities during
the emergency phase that can become more comprehensive once the
programme is consolidated.
regularly to the health coordination team.
Emergency Health Kit– 98
revised NEHK-98 (for 10,000 people for three months) contains the following
supplies to implement the MISP:
is in the NEHK-98 to implement the MISP
for universal precautions for infection control
supplies and drugs for deliveries at health centres Equipment, supplies
and drugs for some obstetric emergencies
supplies and drugs for post-rape management
A booklet describing the NEHK-98 and
how it can be ordered is available from WHO.
A RH Kit
for Emergency Situations has been developed by UNFPA, in cooperation
with others, for use in refugee situations. It complements the NEHK-98
and should be ordered as needed to launch the MISP and support the referral
system. The RH Kit is made up of 12 sub-kits, which can be ordered separately.
Materials and supplies in Subkits 3 and 6 are already available in the
NEHK-98. To order RH sub-kits from UNFPA, contact the UNFPA Country
Director in the country of asylum, the UNFPA Emergency Relief Office
in Geneva or the UNFPA Procurement Office in New York.
Kit is targeted for use in the initial acute phase of the emergency.
Once the situation stabilises, procurement of RH materials and supplies
should be done along with other health programme supply and drug ordering.
A booklet describing the RH Kit and how
it can be ordered is available from UNFPA. (See Appendix Four for contact addresses.)
is in the UNFPA RH Kit
use at primary health care/ health centre level: 10,000 population
for three months
0 Training and Administration
2 Clean delivery sets
3 Post-rape management
4 Oral and injectable contraceptives
5 STD Drugs
use at health centre or referral level: 30,000 population for three
6 Professional midwifery delivery kit
7 IUD insertion
8 Management of the complications 8 of unsafe abortion
9 Suture of cervical and vaginal 8 tears
10 Vacuum extraction
use at the referral level: 150,000 population for three months
11 A – Referral-Level Surgical 11 (reusable equipment)
11 B – Referral-Level Surgical 11 (consumable items and drugs)
12 Transfusion (HIV testing for blood 11 transfusion)
the early phase of the emergency, a limited amount of data should be
collected to assess the implementation of the MISP. Information on mortality
and morbidity by age and sex should be routinely collected during the
early phase of an emergency. Refer to Chapter Nine for more information on these indicators.
selecting MISP indicators from the following list.
of sexual violence:
Monitor the number of cases of sexual violence reported to health
services, protection and security officers.
for universal precautions:
Monitor the availability of supplies for universal precautions,
such as gloves, protective clothing and disposal of sharp objects.
of condom coverage:
Calculate the number of condoms available for distribution to the
of coverage of clean delivery kits:
Calculate the number of clean delivery kits available to cover the
estimated births in a given period of time.
for the RH MISP
or estimate basic demographic information
of women of reproductive age
of men of reproductive age
of pregnant women
of lactating women
and manage the consequences of sexual and gender-based violence
to prevent sexual violence are in place
service able to manage cases of sexual violence
trained (retrained) in prevention and response systems for cases
of sexual violence
in place for adequate practice of universal precautions
procured and distributed
workers trained/ retrained in practice of universal precautions
excess neonatal and maternal morbidity and mortality
delivery kits available and distributed
midwife kits (or equivalent) available at the health centre
competency assessed and retraining undertaken
system for obstetric emergencies functioning
for the provision of comprehensive RH services
information collected (mortality, HIV prevalence, CPR)
identified for future delivery of comprehensive RH services
an organisation(s) and individual(s) to facilitate the MISP
RH Coordinator in place and functioning under the health coordination
focal points in camps and implementing agencies in place
trained and sensitised on technical, cultural, ethical, religious
and legal aspects of RH and gender awareness
for the implementation of the MISP available and used