Historically, humanitarian agencies responding to emergencies – war, civil strife, famine, environmental disasters – did not think about the reproductive health (RH) needs of the people theywere serving. They focused on providing shelter, food, water, and health care to prevent deaths due to infectious diseases.

But RH is a human right and applies equally to refugees, internally displaced persons (IDPs), and others living in humanitarian settings.  In many important respects, refugees are no different from the people in stable settings who have been the focus of development efforts and RH programs for decades. Indeed, before flight from their homes and villages, they may have been the very individuals who participated in such programs. Thus, sound principles of program design, monitoring, and evaluation developed in stable settings may also apply to refugee settings.

However, refugees’ experiences of conflict, flight, and displacement introduce factors that program planners must consider as they establish RH services. The poverty, powerlessness, family dissolution, and social instability characteristic of refugees’ lives may affect their RH desires, their exposure to risk – of HIV and violence particularly – and their capacity to act (McGinn, 2000). RH programs must consider the living situations of all those affected by the conflict, not only the displaced themselves. The displaced may stay in segregated refugee camps or live intermingled with the local population – who are often materially little better off than are the refugees – in villages, towns or cities. In either case, the refugees and the humanitarian organizations that come to serve them change the social, political, economic, and physical environment. Programs must address the issue of equity and the potential for inter-group tension as they determine the services they will offer, and to whom.

The acknowledgment of reproductive rights for refugees places a burden of responsibility upon humanitarian actors to provide the health services refugees need to exercise these rights.

Definition of Terms and Phases of Conflict

The term “refugee,” in legal language, refers to a person who has fled his or her home, has crossed an international border, and is unable or unwilling to return because of persecution based on race, religion, nationality, membership in a particular social group, or political opinion. The term also informally includes persons fleeing war, civil strife, famine, and environmental disasters. IDPs have been forced from their homes but remain within the borders of their own countries. Because countries in conflict are often unable or unwilling to provide needed health and social services to IDPs and because the international community may be averse to overstepping the sovereign rights of states, IDPs may receive little international attention, and victims may go unprotected and unassisted.

All those affected by armed conflict are persons of concern: these include refugees, IDPs, and the host populations residing in the locations of asylum. In general, the terms used here – “refugees,” “displaced,” and “war-affected” – refer to all these affected groups unless otherwise noted.

Phases of Conflict

Complex humanitarian emergencies often fall into phases for guidance in determining program needs and setting priorities. The diagram below (Busza and Lush, 1999) is a useful description of commonly discussed phases. However, conflict is rarely a linear process. A region in conflict often exhibits characteristics of more than one phase at a time as it moves back and forth through the phases.

(Click on diagram to enlarge.)

In the exodus/emergency and post-emergency phases, assessment is typically limited to measuring inputs and functional outputs, specifically logistics. Ironically, evaluators also routinely collect good data on mortality – a long-term outcome measure – at least in closed camp settings, though data are often not age, sex-, or cause-specific. As the population moves into the stabilization and later phases, the data collection system may expand to cover other aspects of the supply or demand environment. In these phases, the programs and monitoring systems may resemble those in development settings and may face many of the same data collection challenges.

Methodological Challenges of Evaluating RH Programs in Emergency Settings

• The destruction of infrastructure and systems in humanitarian settings limits providers’ ability to deliver services and evaluate programs.

Agencies working in conflict and disaster settings must start from scratch to establish service delivery systems and systems to evaluate the effectiveness of services. Delivery of services receives priority over evaluation.

• Refugee populations move, and thus measurement becomes difficult.

Refugees often move more than once. In the early phases of a conflict, large-scale movement can occur in stages as individuals and families make their way to safe havens. Once in a “stable” setting, however, influxes and egresses are common as some family members leave to find work, to return home to harvest their fields, or to test other relocation sites. The evershifting denominator complicates measurement.

• Refugees may view data collection as coercive, and thus data quality may be compromised.

Although a danger of courtesy bias and intimidation in data collection exist in any population, refugees and the displaced depend for their very lives on the agencies seeking information from them. They may perceive that their participation and their responses will determine access to services that are fundamental to survival.

• Data collection is limited to accessible populations.

The published and unpublished literature is biased towards refugees living in stable camp settings, simply because access to other groups – the displaced, those living in scattered sites, those living in insecure areas – is often difficult or impossible. Safety concerns, such as land mines and contact with armed combatants, and practical concerns, such as the inadvisability of traveling at night and the lack of accommodations, limit the ability of staff to travel to deliver services or to collect data. Program staff must guard against generalizing their findings to all refugees and displaced.

• Agencies may not coordinate monitoring efforts among themselves.

The office of the United Nations High Commissioner for Refugees (UNHCR) is the intergovernmental agency responsible for the well-being of refugees (except for IDPs, for whom their own government is responsible). UNHCR, and other coordinating agencies work through many reputable humanitarian and governmental organizations, each of which has its own mission and donors, and finance, personnel, logistics, and recordkeeping systems. International, interagency minimum standards for disaster response, developed through The Sphere Project, have facilitated this coordination task.

• Technically competent staff are in short supply.

International response at the onset of emergencies includes well-trained medical staff to provide some services. However, it is always necessary to engage staff or volunteers from among the refugee population for many tasks; these are the majority of workers, especially as the situation stabilizes and the emergency agencies phase out. Frequently, however, refugees with education and technical skill are not the ones who remain in refugee camps; their social networks provide them with more attractive and safer alternatives. This exodus applies in particular for trained health workers and persons with research or data analysis experience.

• Humanitarian agencies and donors plan for the short term.

Humanitarian agencies are expert in immediate response to emergencies. This is their mission; most are not long-term development agencies. Yet, most of the refugees and displaced in the world are in the stabilization phase, and long-term program objectives are appropriate. Many agencies have worked to ensure that their immediate response is consistent with longer-term program needs to ease the transition in services and data collection and use.

• We have limited program and research experience on reproductive health in forced migration situations to guide us.

We are only beginning to understand the effects of forced migration on RH knowledge, attitudes, practice and, ultimately, on RH status. We have limited experience with how to gather information related to movement, mental health, family dissolution, and social change, yet these factors may be key to understanding the needs, desires, resources, and concerns of populations affected by war. Many people debate the ethics of asking questions of traumatized people for whom services may still be unavailable. We expect that as we gain experience and find answers, this information will be useful to improve services to both refugee and stable populations.

Indicator Selection

The indicators included in this section are those developed by the Inter-agency Working Group on Reproductive Health in Crises, in a guide entitled, Inter-agency Field Manual on ReproductiveHealth in Humanitarian Settings (2010). The indicators are part of the Minimum Initial Service Package for RH in crises, which addresses the emergency phase – i.e., the period of days or weeks at the beginning of a refugee crisis. The indicators described in detail here are those recommended for monitoring implementation of this Minimum Initial Service Package only. The Field Manual also recommends that comprehensive RH services be put in place as soon as possible after the emergency phase and includes indicators for monitoring these more extensive services.

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References:

Inter-agency Working Group on Reproductive Health in Crises.  Inter-agency Field Manual on Reproductive Health in Humanitarian Settings. 2010