Reproductive health in the changing humanitarian context: findings from the IAWG on Reproductive Health in Crises’ 2012-2014 Global Evaluation

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The global landscape for reproductive health in humanitarian settings has changed dramatically since the International Conference on Population and Development (ICPD) in 1994. Mainstreaming of reproductive health into humanitarian health responses has grown, and awareness of the consequences of neglecting reproductive health services, such as maternal and neonatal mortality, HIV transmission, and unsafe abortion, has expanded. Despite these advances, significant gaps remain, and meeting the reproductive health needs of crisis-affected communities is more urgent than ever: the United Nations High Commissioner for Refugees (UNHCR) reported that 51.2 million people remained forcibly displaced due to conflict and persecution by the end of 2013—the largest number since World War II. An additional 22 million were displaced in 2013 by natural disasters.

A concentrated effort to address reproductive health in emergencies commenced in 1995 when a coalition of UN agencies, national and international nongovernmental organizations (NGOs), government agencies, donors, and academic institutions established the Inter-agency Working Group on Reproductive Health in Crisesa (IAWG), an international network dedicated to improving the reproductive health of communities affected by conflict and natural disaster. IAWG arose from a growing concern with the lack of attention to reproductive health, despite increasing evidence of its need in emergency settings. In its first decade, IAWG made large strides in advancing reproductive health through advocacy, research, standard setting, and guidance development, including the publication of the seminal Reproductive Health for Refugees: An Inter-agency Field Manual. The Field Manual was the first technical guidance on implementing reproductive health in emergencies and articulated a minimum standard in reproductive health service delivery—the Minimum Initial Service Package (MISP) for Reproductive Health. IAWG also supported the creation of the Interagency Reproductive Health Kits, twelve kits of essential medicines and supplies, to support rapid implementation of the MISP.

By the early 2000s, IAWG and its partners—including the Reproductive Health Response in Crises (RHRC) Consortium— had achieved substantial gains. A 1999 study documented an increase in evidence, funding, policies, conferences, and new NGOs addressing reproductive health in emergencies, reflecting marked progress in advancing reproductive health on the global humanitarian agenda. From 2002 to 2004, IAWG undertook its first global evaluation to assess progress. The findings confirmed advancements at the policy and implementation levels since the mid-90s, but significant gaps continued across all technical areas, specifically maternal and newborn health, family planning, gender-based violence, and HIV and other sexually transmitted infections (STIs)

IAWG’s second decade, from 2004 to 2014, saw the maturation of the coalition and further advancements to institutionalize reproductive health into humanitarian health responses and improve access to services. Members successfully advocated integrating the MISP as a minimum health standard in the 2004 and 2011 revisions of the Sphere Humanitarian Charter and Minimum Standards in Disaster Response and the Inter-Agency Standing Committee Health Cluster Guide. Through IAWG’s advocacy, the MISP was included as a lifesaving activity eligible for Central Emergency Response Fund funding. In 2009, led by the World Health Organization (WHO) and UN Population Fund (UNFPA), IAWG and partners drafted the Granada Consensus on Sexual and Reproductive Health during Protracted Crises and Recovery, which reaffirmed comprehensive reproductive health as a right in protracted settings and fragile states. The following year IAWG released an updated field-test version of the Field Manual, which included an extra chapter dedicated to comprehensive abortion care—a particularly neglected area in reproductive health service provision—as well as outlined additional priority activities to the MISP. IAWG also served as a platform to spearhead two ground-breaking, complementary programs: the Reproductive health Access, Information and Services in Emergencies (RAISE) Initiative, which focuses on expanding comprehensive reproductive health services in crises, and the Sexual and Reproductive Health Programme in Crisis and Post-Crisis Situations (SPRINT), which works to enhance access to the priority services of the MISP. These initiatives are among the first international efforts to systematically scale up capacity and implementation of reproductive health services in emergencies at the national level.

Membership expanded as IAWG actively sought to decentralize and establish regional networks. By the end of 2014, IAWG had 1,680 individual members representing 124 countries and 450 different agencies—a significant increase from approximately 50 members in 2004. With more members, IAWG was able to establish regional chapters as well as roughly ten sub-working groups on specialized issues related to reproductive health, such as new technologies, urban displacement, and disaster risk reduction. Indeed, IAWG’s disaster risk reduction and emergency preparedness efforts, including the SPRINT Initiative and the reproductive health group within the UN International Strategy for Disaster Reduction, have helped promote a comprehensive approach to reproductive health that considers both preand post-crisis phases. IAWG has galvanized the field despite lack of sustained, dedicated funding since the coalition’s inception.

From 2012 to 2014, IAWG conducted a second global review to assess progress, document gaps, and determine future directions. Seven complementary studies were undertaken to provide a snapshot of the field. The studies build on those undertaken for the 2004 evaluation and explore key aspects of the field, including new research, changes in funding and institutional capacity, and implementation of both MISP and comprehensive reproductive health services in selected settings. Four studies are presented in this Supplement: a systematic review of peerreviewed research evaluating reproductive health programs in crises from 2004 to 2013; an assessment of MISP implementation in two settings hosting Syrian refugees in Jordan; an evaluation of the availability and quality of and access barriers to reproductive health services in crisis-affected settings in Burkina Faso, the Democratic Republic of the Congo (DRC), and South Sudan; and a systematic analysis of reproductive health in humanitarian health and protection funding proposals for 2002 to 2013. Three additional studies, not yet published, include a long-term trend analysis study that tracked official development assistance for reproductive health to 18 conflict-affected countries for 2002 to 2011 (unpublished observations, Patel, Dahab, Tanabe, Murphy, Ettema, Guy, Roberts), a retrospective analysis of selected reproductive health indicators from UNHCR’s Health Information System across 56 refugee camps in ten countries from 2007 to 2013 (unpublished observations, Whitmill, Tomczyk, Blanton, Doraiswamy, Haskew, Cornier, Schilperood, Spiegel), and a survey of humanitarian and development agencies that explored changes in their capacity to address reproductive health in crises since 2004 (unpublished observations, Tran, Dawson, Meyers, Krause, Hickling). The findings revealed substantial progress since 2004—reproductive health is squarely situated on the humanitarian agenda—but multiple gaps were documented across alltechnical areas punctuated by overarching issues in commodity security and community engagement.


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