CONTENTS

CONFLICT AND HEALTH 2 Advancing reproductive health on the humanitarian agenda: the 2012-2014 global review Sarah K Chynoweth

CONFLICT AND HEALTH 17 Evaluations of reproductive health programs in humanitarian settings: a systematic review Sara Casey

CONFLICT AND HEALTH 36 Tracking humanitarian funding for reproductive health: a systematic analysis of health and protection proposals from 2002-2013 Mihoko Tanabe, Kristen Schaus, Sonia Rastogi, Sandra K Krause, Preeti Patel

BJOG : An International Journal of Obstetrics and Gynaecology 55 Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011 Mihoko Tanabe, Kristen Schaus, Sonia Rastogi, Sandra K Krause, Preeti Patel

i CONFLICT AND HEALTH 72 Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies Sara E Casey, Sarah K Chynoweth, Nadine Cornier, Meghan C Gallagher, Erin E Wheeler

CONFLICT AND HEALTH 94 Reproductive health services for Syrian refugees in Zaatri Camp and Irbid City, Hashemite Kingdom of Jordan: an evaluation of the Minimum Initial Services Package Sandra Krause, Holly Williams, Monica A Onyango, Samira Sami, Wilma Doedens, Noreen Giga, Erin Stone, Barbara Tomczyk

CONFLICT AND HEALTH 110 Retrospective analysis of reproductive health indicators in the United Nations High Commissioner for Refugees post-emergency camps 2007–2013

Jennifer Whitmill, Curtis Blanton, Sathyanarayanan Doraiswamy, Nadine Cornier, Marian Schilperood, Paul Spiegel and Barbara Tomczyk

PLOS ONE 128 Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study Nguyen-Toan Tran, Angela Dawson, Janet Meyers, Sandra Krause, Carina Hickling, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis

ii Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

INTRODUCTION Open Access Advancing reproductive health on the humanitarian agenda: the 2012-2014 global review

Introduction agencies, national and international The global landscape for reproductive health nongovernmental organizations (NGOs), in humanitarian settings has changed government agencies, donors, and academic dramatically since the International institutions established the Inter-agency Conference on Population and Development Working Group on Reproductive Health in (ICPD) in 1994. Mainstreaming of Crisesa (IAWG), an international network reproductive health into humanitarian health dedicated to improving the reproductive responses has grown, and awareness of the health of communities affected by conflict consequences of neglecting reproductive and natural disaster. IAWG arose from a health services, such as maternal and growing concern with the lack of attention neonatal mortality, HIV transmission, and to reproductive health, despite increasing unsafe abortion, has expanded. Despite these evidence of its need in emergency settings advances, significant gaps remain, and [3]. In its first decade, IAWG made large meeting the reproductive health needs of strides in advancing reproductive health crisis-affected communities is more urgent through advocacy, research, standard setting, than ever: the United Nations High and guidance development, including the Commissioner for Refugees (UNHCR) publication of the seminal Reproductive Health reported that 51.2 million people remained for Refugees: An Inter-agency Field Manual [4]. forcibly displaced due to conflict and The Field Manual was the first technical persecution by the end of 2013—the largest guidance on implementing reproductive number since World War II [1]. An additional health in emergencies and articulated a 22 million were displaced in 2013 by natural minimum standard in reproductive health disasters [2]. Figure 1. service delivery—the Minimum Initial A concentrated effort to address Service Package (MISP) for Reproductive reproductive health in emergencies Health.b IAWG also supported the creation commenced in 1995 when a coalition of UN of the Interagency Reproductive Health Kits, twelve kits of essential medicines and Correspondence: [email protected] supplies, to support rapid implementation of University of New South Wales, High St, Kensington, NSW 2052, Australia the MISP [5].

@ 2015 Chynoweth; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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. 1 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

Figure 1

By the early 2000s, IAWG and its UN Population Fund (UNFPA), IAWG and partners—including the Reproductive Health partners drafted the Granada Consensus on Response in Crises (RHRC) Consortiumc— Sexual and Reproductive Health during had achieved substantial gains. A 1999 study Protracted Crises and Recovery, which documented an increase in evidence, reaffirmed comprehensive reproductive funding, policies, conferences, and new health as a right in protracted settings and NGOs addressing reproductive health in fragile states [11]. The following year IAWG emergencies, reflecting marked progress in released an updated field-test version of the advancing reproductive health on the global Field Manual, which included an extra humanitarian agenda [6]. From 2002 to 2004, chapter dedicated to comprehensive abortion IAWG undertook its first global evaluation care—a particularly neglected area in to assess progress [7]. The findings reproductive health service provision—as confirmed advancements at the policy and well as outlined additional priority activities implementation levels since the mid-90s, but to the MISP [12]. IAWG also served as a significant gaps continued across all technical platform to spearhead two ground-breaking, areas, specifically maternal and newborn complementary programs: the Reproductive health, family planning, gender-based health Access, Information and Services in violence, and HIV and other sexually Emergencies (RAISE) Initiative, which transmitted infections (STIs). focuses on expanding comprehensive IAWG’s second decade, from 2004 to reproductive health services in crises, and the 2014, saw the maturation of the coalition Sexual and Reproductive Health Programme and further advancements to institutionalize in Crisis and Post-Crisis Situations reproductive health into humanitarian health (SPRINT), which works to enhance access responses and improve access to services. to the priority services of the MISP. These Members successfully advocated integrating initiatives are among the first international the MISP as a minimum health standard in efforts to systematically scale up capacity and the 2004 and 2011 revisions of the Sphere implementation of reproductive health Humanitarian Charter and Minimum services in emergencies at the national level. Standards in Disaster Response and the Membership expanded as IAWG actively Inter-Agency Standing Committee Health sought to decentralize and establish regional Cluster Guide[8,9]. Through IAWG’s networks. By the end of 2014, IAWG had advocacy, the MISP was included as a life- 1,680 individual members representing 124 saving activity eligible for Central Emergency countries and 450 different agencies—a Response Fund funding [10]. In 2009, led by significant increase from approximately 50 the World Health Organization (WHO) and members in 2004. With more members, 2 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

IAWG was able to establish regional chapters additional studies, not yet published, include as well as roughly ten sub-working groups on a long-term trend analysis study that tracked specialized issues related to reproductive official development assistance for health, such as new technologies, urban reproductive health to 18 conflict-affected displacement, and disaster risk reduction. countries for 2002 to 2011 (unpublished Indeed, IAWG’s disaster risk reduction and observations, Patel, Dahab, Tanabe, Murphy, emergency preparedness efforts, including Ettema, Guy, Roberts), a retrospective the SPRINT Initiative and the reproductive analysis of selected reproductive health health group within the UN International indicators from UNHCR’s Health Strategy for Disaster Reduction, have helped Information System across 56 refugee camps promote a comprehensive approach to in ten countries from 2007 to 2013 reproductive health that considers both pre- (unpublished observations, Whitmill, and post-crisis phases. IAWG has galvanized Tomczyk, Blanton, Doraiswamy, Haskew, the field despite lack of sustained, dedicated Cornier, Schilperood, Spiegel), and a survey funding since the coalition’s inception. of humanitarian and development agencies From 2012 to 2014, IAWG conducted a that explored changes in their capacity to second global review to assess progress, address reproductive health in crises since document gaps, and determine future 2004 (unpublished observations, Tran, directions. Seven complementary studies Dawson, Meyers, Krause, Hickling). The were undertaken to provide a snapshot of findings revealed substantial progress since the field. The studies build on those 2004—reproductive health is squarely undertaken for the 2004 evaluation and situated on the humanitarian agenda—but explore key aspects of the field, including multiple gaps were documented across new research, changes in funding and alltechnical areas punctuated by overarching institutional capacity, and implementation of issues in commodity security and community both MISP and comprehensive reproductive engagement. Figure 2. health services in selected settings. Four studies are presented in this Supplement: a Progress and gaps systematic review of peerreviewed research Overall, the studies documented broad evaluating reproductive health programs in progress for reproductive health in crises from 2004 to 2013 [13]; an assessment humanitarian settings. Tanabe et al. found of MISP implementation in two settings that of the roughly 11,300 health and hosting Syrian refugees in Jordan [14]; an protection proposals issued between 2002 evaluation of the availability and quality of and 2013, almost 4,000 contained and access barriers to reproductive health reproductive health components, more than services in crisis-affected settings in Burkina a third of the issued proposals [16]. The Faso, the Democratic Republic of the Congo number of proposals including reproductive (DRC), and South Sudan [15]; and a health increased by an average of 22% per systematic analysis of reproductive health in year, while the proportion of health and humanitarian health and protection funding protection sector proposals containing proposals for 2002 to 2013 [16]. Three reproductive health increased by an average 3 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

Figure 2

of 10% per year. Preliminary findings from funding and absolute funding received for the long-term trend analysis indicate reproductive health in humanitarian appeals substantial increase in official development have increased since 2002, Tanabe et al. assistance for reproductive health for determined that just 43% of these funding conflict-affected countries from 2002-2011 requests were met over the last 12 years, (unpublished observations, Patel, Dahab, slightly above the health sector average of Tanabe, Murphy, Ettema, Guy, Roberts). 41% and well below the total humanitarian These studies demonstrate increased sector average of 68% [16]. Preliminary awareness among humanitarian actors of the findings from the long-term trend analysis need to implement reproductive health indicate that the bulk of increased overseas services in a crisis response. The trend is also development assistance for reproductive reflected by the preliminary findings of the health in conflict-affected countries was institutional capacity survey that documented attributable to HIV-related activities increased organizational investment in (unpublished observations, Patel, Dahab, human and financial resources to address Tanabe, Murphy, Ettema, Guy, Roberts). The reproductive health in humanitarian settings preliminary findings also show disparity in (unpublished observations, Tran, Dawson, the disbursement of overseas development Meyers, Krause, Hickling). assistance for reproductive health between At the same time, although requests for conflict-affected countries and non-conflict 4 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

affected countries in the same income average of almost 40% and 2.4%, category and between countries affected by respectively, per year [16]. conflict; for example, the average annual per The other studies paint a more complex capita reproductive health overseas picture. Casey et al.’s research revealed development assistance disbursed to least- significant gaps in the clinical components developed nonconflict-affected countries of the MISP in three settings well past the was 57% higher than to leastdeveloped acute emergency phase [15]. Similarly, conflict-affected countries. preliminary findings from the analysis of reproductive health indicators from MISP UNHCR’s Health Information Systems in 56 The MISP comprises the priority stable refugee camps indicate wide variation reproductive health activities to be in condom distribution and provision of implemented in an acute emergency and post-exposure prophylaxis for HIV as part should be built upon with comprehensive of clinical management of rape—both key programming as soon as possible. In 2004, activities of the MISP (unpublished the first global evaluation found that observations, Whitmill, Tomczyk, Blanton, attention to the MISP was gaining ground, Doraiswamy, Haskew, Cornier, Schilperood, but implementation was not systematic, Spiegel). Regarding evaluation of particularly during the early days of a reproductive health programming in response, and awareness among health actors humanitarian settings, Casey’s systematic remained low [7]. Over the past decade, review found no peer-reviewed papers assessments spearheaded by the Women’s that evaluated MISP implementation Refugee Commission, UNFPA, and other comprehensively since 2004 [13]. IAWG members have chronicled steady improvement in MISP awareness and Maternal and newborn health implementation globally [17-21]. For the Progress in maternal and newborn health 2014 global review, Krause et al. found followed a similar trajectory. In 2004, the services and key elements to support MISP global evaluation found that some maternal implementation largely in place in two and newborn health services were available settings serving Syrian refugees in Jordan in stable refugee settings, but implementation [14]; preliminary findings from the of antenatal care and emergency obstetric institutional capacity study show increasing care lagged [7]. The 2014 review documented attention to reproductive health coordination important progress in advancing maternal by the agencies surveyed (unpublished and newborn health and its integration into observations, Tran, Dawson, Meyers, Krause, primary health care services. Maternal and Hickling). Tanabe et al. determined that, newborn care comprised the largest among humanitarian health and protection proportion (56%) of all reproductive health appeals submitted between 2009 and 2013, components in humanitarian health appeals proposals that included all of the from 2009 to 2013 [16]. It was also the most components of the MISP and those with funded, receiving 56% of requested funds, partial MISP components increased an and received the most amount of absolute 5 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

funds—$684.8 million USD. Casey’s for proportion of live births performed by systematic review identified seven papers that caesarian section (5% to 15%), and all but described evaluations of humanitarian two countries were far below the standard of maternal and newborn health programs since 100% of all births attended by a skilled 2004, demonstrating that some evaluation is health worker (unpublished observations, occurring [13]. Preliminary findings from the Whitmill, Tomczyk, Blanton, Doraiswamy, study of 56 UNHCR refugee camps across Haskew, Cornier, Schilperood, Spiegel). ten countries show that screening for syphilis Further, maternal and infant deaths appeared as part of antenatal care—a significant gap to be underreported across all ten countries. in the 2004 evaluation—increased over time in two countries and was consistently high in Comprehensive abortion care a third, although most camps did not meet Comprehensive abortion care, which desired screening levels across settings includes postabortion care and safe abortion, (unpublished observations, Whitmill, is an essential component of reproductive Tomczyk, Blanton, Doraiswamy, Haskew, health and is particularly important in Cornier, Schilperood, Spiegel). settings with limited access to family Despite this progress, gaps remain, planning and vulnerability to sexual particularly regarding emergency obstetric violence—both of which characterize many and newborn care. A closer analysis of the humanitarian contexts. Safe abortion saves trends in humanitarian appeals divulged that lives: UNFPA estimates that 25% to 50% of antenatal and postnatal activities were more maternal deaths in refugee settings are frequently mentioned in proposals than due to complications of unsafe abortion [22]. emergency obstetric care [16]. Although Yet abortion-related services have been Krause et al. found emergency obstetric and historically neglected in humanitarian newborn care largely in place in the two responses, in part due to their highly settings assessed in Jordan [14], Casey et al. politicized nature as well as health providers’ determined that only one of five hospitals and communities’ misconceptions of the and one of 58 health centers across three restrictiveness of national law [23,24]. humanitarian settings met the criteria to Indeed, the 2004 evaluation found limited adequately provide comprehensive and basic post-abortion care available and safe emergency obstetric and newborn care, abortion was not assessed [7]. Ten years later, respectively [15].d These differences across the 2014 review documented some settings likely reflect the relative availability improvements in post-abortion care but a of these services prior to the crisis. Indeed, critical dearth of access to safe abortion the availability of this care in Jordan is within the extent of national law remained. unsurprising given its advanced health care In Jordan, post-abortion care was system as opposed to the weak health generally available for Syrian refugees in the systems in Burkina Faso, DRC, and South two settings assessed [14]. Casey et al.’s three- Sudan. Preliminary findings from the study country study discovered that all assessed of 56 refugee camps in ten countries show hospitals met the criteria to adequately that none of the countries met the standard provide post-abortion care, although 6 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

availability was variable among health centers family planning, the smallest of all [15]. Still, post-abortion care was severely components assessed; long-acting and lacking in humanitarian health appeals from permanent methods were rarely mentioned 2002 to 2013 [16], and the systematic review [16]. Of the 63 facilities assessed in Burkina found no published studies that evaluated Faso, DRC, and South Sudan, many provided any component of comprehensive abortion pills and injectables, but again, emergency care [13]. Further, safe abortion was contraception as a method of family neglected across all studies in terms of planning and long-acting and permanent funding, evaluation, and implementation [13- methods were scarce [15]. Six of the 36 16], although Krause et al. did find abortion papers identified in Casey’s systematic review available, within Jordan’s legal framework, in evaluated family planning programming, two hospitals [14]. although all but one focused on shortacting methods [13]. At the same time, the MISP Family planning study in Jordan did find wide availability of Comprehensive family planning services, IUDs in addition to short- acting methods which can avert up to 32% of maternal [14], suggesting these methods are more deaths and almost 10% of childhood deaths likely to be provided in settings where they [12], have also long been overshadowed by are already commonly used. other pressing health needs. In 2004, the IAWG evaluation found relatively wide Gender-based violence availability of short-acting methods, In 2004, gender-based violence was an specifically oral contraceptive pills and emerging area and, unsurprisingly, the injectables [7]. However, long-acting and weakest of the reproductive health permanent methods were lacking, despite components assessed in the global evaluation evidence that a wide choice of methods [7]. Gender-based violence is a broad field; raises overall contraceptive use and can reproductive health actors are responsible for enhance cost-effectiveness of programming providing good quality clinical care for [25,26]. Emergency contraception as a survivors of sexual violence and ensuring method of family planning was not assessed protection measures are in place so clients in the 2004 evaluation. can safely access services. The field has Despite more concerted efforts to bring matured and expanded significantly over the family planning to the fore, such as IAWG’s past decade. Indeed, the 2014 review 2010 statement highlighting family planning documented considerable progress in terms as a life-saving intervention in humanitarian of funding, policies, and programming, settings [27], most of the studies from the yet program evaluation, prevention efforts, current review reflected limited progress and systematic, comprehensive clinical relative to the other components of management for rape survivors remained reproductive health since 2004. Tanabe et al. limited [13-15]. found that, of the reproductive health Preliminary findings from the UNHCR components in humanitarian health appeals Health Information System study show that, from 2009 to 2013, only 14.9% contained although rape appeared to be underreported, 7 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

five of the ten countries consistently met the health in humanitarian settings similarly standard of 100% of eligible survivors found extremely limited research on gender- receiving post-exposure prophylaxis within based violence programming [28]. 72 hours of an assault to minimize HIV transmission (unpublished observations, HIV and other STIs Whitmill, Tomczyk, Blanton, Doraiswamy, While the area of gender-based violence is Haskew, Cornier, Schilperood, Spiegel). expanding, HIV in emergencies has long Gender-based violence, as related to been a field in its own right. HIV has reproductive health programming, historically received disproportionate more comprised the second highest (46%) of all funding and attention relative to other reproductive health proposals in reproductive health areas [29]. Indeed, humanitarian health and protection appeals preliminary findings from the long-term from 2009 to 2013, a total increase of 34% funding trend analysis show that the upsurge over five years [16]. This suggests increasing in total official development assistance- attention to gender-based violence by related reproductive health disbursements implementing agencies. Donor support to was largely due to a substantial increase in gender-based violence totaled $308.9 million HIV funding (unpublished observations, USD, a significant amount, although only Patel, Dahab, Tanabe, Murphy, Ettema, Guy, 37% of the total request was met over the Roberts). Examining humanitarian appeals, five-year period [16]. Tanabe et al., however, reported a leveling of The other studies highlighted concerning the field: since 2009, proposals that include gaps. The MISP assessment in Jordan found HIV have declined whereas funding for weak protection measures against sexual other reproductive health areas has increased violence generally and only one assessed site [16]. had skilled staff and sufficient supplies to The 2004 global evaluation found provide clinical care for rape survivors [14]. uneven availability of condoms and STI In the evaluation of reproductive health treatment as well as very limited coverage of services across three settings, only three out anti-retroviral therapy for people living with of 63 total facilities met the criteria to HIV [7]. Now, ten years later, the 2014 adequately provide selected elementse of review identified some progress in the clinical management of rape, and it was settings assessed, particularly regarding unclear whether these three facilities prevention of mother-to-child transmission provided all components of the minimum and antiretroviral therapy, but gaps generally package of post-rape treatment [15]. The mirrored those from a decade ago. Krause et systematic review found a plethora of al. and Casey et al. found sporadic availability descriptive papers that reported prevalence of HIV and other STI services across four and types of sexual violence since 2004— settings [14,15]; anti-retroviral therapy was which were noticeably lacking a decade available at large referral hospitals, but rarely ago—but none that evaluated the at primary care level, despite its inclusion as effectiveness of clinical management of rape an addition to the MISP in the 2010 Field services [13]; a 2013 evidence review of Manual and as a minimum standard in the 8 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

IASC Guidelines for Addressing HIV in evident with Krause et al. finding Humanitarian Settings [12,30]. Preliminary reproductive health services, with the findings from UNHCR’s Health Information exception of family planning for unmarried System data also showed inconsistent adolescents, relatively accessible for provision of condoms in 56 refugee camps adolescent Syrian refugees in Jordan [14]; from 2007 to 2013 (unpublished Casey identified five papers that evaluated observations, Whitmill, Tomczyk, Blanton, adolescent HIV programs in humanitarian Doraiswamy, Haskew, Cornier, Schilperood, settings [13]. Yet few adolescent-friendly Spiegel). Casey identified an abundance of services were in place across the three studies that evaluated anti-retroviral settings assessed by Casey et al. [15], and programs, which generally found that patient Tanabe et al. found limited mainstreaming of outcomes in conflict and post-conflict adolescents in health and protection-related settings are comparable to stable settings funding proposals [6]. Grey literature also [13], suggesting that we know what works documents limited availability of adolescent but need to do it more systematically. reproductive health programs in Attention to HIV continued to overshadow humanitarian settings [31]. other STI services across all studies, even Regarding reproductive health services though untreated STIs can lead to for internally displaced persons, the 2004 complications in pregnancy, infertility, evaluation and other research primarily reproductive cancers, and enhanced focused on maternal health, found better transmission of HIV. reproductive health outcomes in stable refugee camp settings than in neighboring Additional findings host communities or in refugees’ home Preliminary findings from a survey of countries [7,32-34]. In the selected settings development and humanitarian organizations for the 2014 review, the studies established mirrored the findings above. The that, although services for Syrian refugees in humanitarian and development agencies Jordan were markedly more available and surveyed reported increased attention to accessible than for those internally displaced MISP and all technical areas since 2004 as in DRC, services for refugees in camps in well as more efforts to address disaster risk South Sudan were comparatively less reduction, accountability, and inter-agency available and of poorer quality. Among coordination. They also reported, however, Malian refugees in Burkina Faso, some limited attention to safe abortion and cervical reproductive health services, such as STI care cancer screening and treatment (unpublished and prevention-of-mother-tochild observations, Tran, Dawson, Meyers, Krause, transmission of HIV, were more consistently Hickling). available at government-run clinics for the Two notable findings from the 2004 surrounding host population than in camp evaluation were the lack of reproductive health centers. In the assessed settings, health services for adolescents and internally availability and access were contingent on a displaced, as opposed to refugee, populations complex constellation of factors, such as [7]. In the 2014 review, some progress was humanitarian space, funding dedicated to the 9 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

reproductive health response, the robustness key barriers to good quality care. Negative of the setting’s health system, and whether provider attitudes and behaviors, such as services were commonly available before the disrespect towards women seeking family emergency. planning services, hindered some people One of the more striking and urgent from seeking care. Restrictive policies and findings of the 2014 evaluation was that, misinformation about existing policies even when reproductive health services were prevented implementation of critical in place, uptake of many services lagged services, and poor quality data collection across all settings. Many affected undermined service monitoring. Some gaps communities were unaware of existing in care resulted from a dearth of skilled staff. services or did not know of their benefits. Although integration of reproductive health Even those who could identify advantages— into comprehensive primary health care was such as accessing post-exposure prophylaxis evident in some sites, further efforts are for HIV within 72 hours after rape— needed for effective integration across all reported that communities largely shunned levels of care. services, citing socio-cultural barriers such as shame and anxieties about possible social Considerations for future directions sanctions. This finding challenges the “if you The studies for the 2014 IAWG global build it, they will come” assumption that at review documented considerable progress in times permeates health programming. the field since the previous evaluation a Reproductive health refracts cultural decade ago. Funding and awareness have sensitivities, and effective programming increased significantly, and service provision requires community mobilization activities, has expanded. However, programmatic particularly for services to which the needs continue to outweigh financial community may not have previously had support, implementation is not systematic access. IAWG has made some inroads in and is of variable quality, and evidence for recognition of this, such as the inclusion of program efficacy remains scarce. The review “ensuring community awareness of available spotlighted poor commodity management services” as an activity of the MISP [12] and and security, limited availability of the development of behavior change comprehensive abortion care, and lack of communication materials [35]. Notably, community mobilization to increase Casey et al. documented a significant uptake reproductive health service uptake as of facility-based delivery services across particularly critical gaps. three settings as a result of outreach by The Nobel Prize-winning economist health actors, highlighting that behavior Elinor Ostrom imagined the ideal aid system change to increase use of reproductive health as one that would “reward people for services is possible with the appropriate developing imaginative ideas that draw on strategy. the complexity of the real world, that leave Many of the other challenges identified people in developing countries more in these studies are long-standing. Poor autonomous, less dependent, and more commodity management and security were capable of crafting their own future” [36]. 10 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

She proposed that, in a rapidly evolving includes, for example, funders supporting global society, the nature of change is non- community involvement in the design and linear and is achieved not through delivery of reproductive health services, pre-fabricated solutions but through creating national governments addressing policy adaptive, dynamic systems. Many of the barriers to reproductive health service strategies used by IAWG and other actors implementation, and national medical and advancing reproductive health on the nursing schools integrating reproductive humanitarian agenda align with Ostrom’s health into their curricula. Humanitarian and complexity approach. Their efforts have development gencies addressing often been innovative, responsive, and multi- reproductive health must engage, coordinate, faceted, involving local communities up to and reinforce each others’ work, and donors the highest levels of international bodies and are called upon to support cohesive engaging with all phases of the emergency programming that integrates both preand management cycle. post-crisis efforts. With the increasing The way forward would benefit from urbanization of displacement—as applying dynamic approaches that knit demonstrated in Krause et al.’s study— together disparate elements of the implementing agencies need to adapt and emergency management universe, including develop appropriate operational frameworks pre-crisis preparedness and risk reduction and forge new relationships with municipal efforts, crisis response interventions, and authorities and urban service providers. early recovery and rehabilitation activities. Preliminary findings from the institutional Humanitarian response must be integrated as capacity survey indicate that an increasing an essential piece of health systems work and number of stakeholders are addressing reproductive health as an essential emergency preparedness, disaster risk component of health. Indeed, the findings reduction, and recovery measures related to from the 2014 review indicate that the reproductive health, but much more effort is relative robustness of the pre-existing health needed to systematically and sustainably care system and the availability of bridge the humanitarian-development divide. reproductive health services before an Casey et al. and Krause et al.’s studies emergency determine the availability and highlight the urgent need to address uptake of these services during the response reproductive health commodity security. and recovery. Long before a crisis, donors, Ministries of Health and health NGOs must UN agencies, governments, and international strengthen commodity management and national NGOS, among others, must processes to prevent stock-outs and provide support the capacity of Ministries of Health consistent access to care. At the global level, and Disaster Management, national and with donor support, IAWG could link with community-based organizations, health the Reproductive Health Supplies Coalition workers, and communities themselves to and other development actors to spearhead strengthen health systems with an emphasis a concerted effort to promote effective on comprehensive reproductive health, reproductive health supply chain accessibility, and resilience-building. This management from the onset of a crisis 11 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

response throughout recovery. the weak evidence base as identified in the The significant growth in funding for literature review, academic institutions could and implementation of gender-based spearhead more systematic research and violence and HIV programming, as found by program evaluation to identify better ways to Tanabe et al., illustrates the expansion of serve the reproductive health needs of crisis- these fields over the past decade. As such, the affected communities. protection and health clusters/sectors, led by In order to realize Ostrom’s vision for UNHCR and WHO, respectively, as well as aid, UN agencies, donors, and international the gender-based violence area of NGOs must listen to, engage, and work with responsibility, co-led by UNFPA and local, national, and government agencies in UNICEF, must strengthen coordination and a way that addresses power dynamics and delineation of roles to support an aligned promotes ownership and leadership. The approach and integrated interventions. 2014 review clearly highlights that Gender-based violence and HIV focal points humanitarian and development actors must ought to maintain linkages with reproductive identify and develop effective strategies to health actors to ensure a harmonized meaningfully engage affected communities response by, for example, attending to increase use of reproductive health respective coordination meetings in the field. services, meet their reproductive health Indeed, the lynchpin for an effective needs, and augment participation in the reproductive health humanitarian response is programs that affect their lives. sustained, inter-agency reproductive health Implementing agencies can explore coordination with a designated lead agency; contextually appropriate new technologies, funders are obliged to support this type of such as social media and mobile coordination and not just direct service technologies, to increase two-way provision. communication with communities [37]. Casey et al. and Krause et al.’s studies The studies also bring to the fore the demonstrate the need to enhance providers’ marked lack of attention to adolescent knowledge base and address personal beliefs reproductive health in terms of funding, that affect professional conduct. Service access to services, programming, and providers should explore competency-based program evaluation; donors and clinical trainings on reproductive health implementing agencies must prioritize within a rights-based framework. These two adolescents as well as other marginalized studies also show the importance of a groups, such as people with disabilities, sex coherent transition from MISP to workers, elderly, and lesbian, gay, bisexual, comprehensive reproductive health services, and transgender persons, to ensure they as outlined in the Granada Consensus [11]. access and enjoy good quality reproductive Preliminary findings from the Health health care. In addition, Casey et al.’s research Information System study as well as Casey et in Burkina Faso, DRC, and South Sudan al.’s study indicate that UNHCR and sheds light on the challenges of providing implementing agencies must strengthen their good quality care in remote settings with data collection and management. To enhance limited health providers; more attention to 12 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

task-sharing to address human resource gaps of agencies to work together [36]. and to developing alternative service delivery Collaborative efforts that embrace holistic, models can help facilitate the provision of adaptive approaches, such as IAWG at the services even in the most hard to reach areas. global level and many national and These and other efforts should be community-based networks at the field level, underpinned by humanitarian principles and are critical to continue to effectively move grounded in a culture that fosters the agenda forward. These partnerships need accountability, learning, adaptation, and to be supported and consolidated. Indeed, flexibility. Tanabe et al.’s study as well as sustained, dedicated, predictable funding to preliminary findings from the long-term maintain the coordination of IAWG is trend analysis of official development essential as it leads the coordinated effort to assistance demonstrate the need for protect and promote the sexual and increased funding for reproductive health in reproductive well-being of communities crises. Donor governments such as Australia, affected by humanitarian crises around the Belgium, and the U.S. have thankfully world. stepped up in recent years to support humanitarian reproductive health and List of abbreviations protection programming, but more donor DRC: Democratic Republic of the Congo; IAWG: champions are required to close the funding Inter-agency Working Group on Reproductive Health in Crises; ICPD: International Conference gap, ensure equitable funding across on Population and Development; MISP: reproductive health areas, and support fluid, Minimum Initial Service Package (for innovative humanitarian programs rather Reproductive Health); NGO: Nongovernmental than short-term, quantifiable interventions. organization; RAISE: Reproductive health Access, Information and Services in Emergencies; RHRC Multi-sectoral efforts to advance Consortium: Reproductive Health Response in reproductive health in crises are also needed Conflict Consortium; SPRINT: Sexual and at the global level. The architects of the Reproductive Health Programme in Crisis and Sustainable Development Goals, for Post-Crisis Situations; STI: Sexually transmitted infection; UNFPA: United Nations Population example, should integrate comprehensive Fund; UNHCR: United Nations High reproductive health care for communities Commissioner for Refugees; WHO: World Health affected by humanitarian crises into the post- Organization. 2015 agenda. Reproductive health and gender issues remain on the periphery of Competing interests The author is a co-author of one of the studies climate change adaptation and mitigation included in the Conflict and Health Supplement planning, and climate change leaders should for the 2012-2014 IAWG Global Review: Progress ensure reproductive health actors are at the and gaps in reproductive health services in three table. humanitarian settings: mixedmethods case studies by Casey et al. There is no panacea to addressing reproductive health needs in increasingly Authors’ information complex humanitarian crises. But we do The author has been a member of the Inter- know that effective humanitarian action is agency Working Group on Reproductive Health in Crises since 2003. contingent on the capacity, ability, and desire 13 Chynoweth Conflict and Health 2015, 9(Suppl 1):I1 http://www.conflictandhealth.com/content/9/S1/I1

Acknowledgements 10. Central Emergency Response Fund: Lifesaving I am grateful to the IAWG Global Review Criteria and Sectoral Activities Guidelines. 2010. Steering Committee and the authors of the 11. World Health Organization, UN Population Fund, studies of the 2012-2014 Global Review. Escuela Andaluza de Salud Pública: Sexual and Reproductive Health during Protracted Crises and Declarations Recovery: Granada Consensus. Geneva; 2009. This article has been published as part of Conflict 12. Inter-agency Working Group on Reproductive and Health Volume 9 Supplement 1, 2015: Taking Health in Crises: Inter-agency Stock of Reproductive Health in Humanitarian Field Manual on Reproductive Health in Settings: 2012-2014 Inter-agency Working Group Humanitarian Situations. Geneva; 2010. on Reproductive Health in Crises’ Global Review. The full contents of the supplement are available 13. Casey SE: Evaluations of reproductive health online at http://www.conflictandhealth.com/ programs in humanitarian settings: a systematic supplements/9/S1. Funding for this supplement review. Confl Health 2015, was provided by the MacArthur Foundation. 9(Suppl 1):S1 [http://www.conflictandhealth.com/content/9/S1/S1 Published: 26 March 2015 ]. 14. Krause SK, Williams H, Onyango MA, Sami S, Doedens W, Giga N, Stone E, Tomczyk B: References Reproductive health services for Syrian refugees in 1. UNHCR: Global Trends Report 2013. Geneva; 2014. Zaatri Camp and Irbid City, Hashemite Kingdom of Jordan: An evaluation of the Minimum Initial 2. Internal Displacement Monitoring Centre: Global Services Package. Confl Health 2015, 9(Suppl 1):S4. Estimates 2014: People Displaced by Disasters. Geneva; 2014. 15. Casey SE, Chynoweth SK, Cornier N, Gallagher M, Wheeler EE: Progress and gaps in reproductive 3. Wulf D: Refugee Women and Reproductive Health health services in three humanitarian settings: Care: Reassessing Priorities. Women’s Refugee mixed-methods case studies. Confl Health 2015, Commission 1994. 9(Suppl 1):S3. 4. Inter-agency Working Group on Reproductive 16. Tanabe M, Schaus K, Tastogi S, Krause SK, Patel P: Health in Crises: Reproductive Health for Refugees: Tracking humanitarian funding for reproductive An Inter-agency Field Manual. Geneva; 1999. health: a systematic analysis of health and 5. Inter-agency Working Group on Reproductive protection proposals from 2002-2013. Confl Health Health in Crises: Inter-agency Reproductive Health 2015, 9(Suppl 1):S2. Kits for Crisis Situations. 2011. 17. Women’s Refugee Commission: Still in Need: 6. Palmer CA, Zwi AB: The emerging international Reproductive Health Care for Afghan Refugees in policy agenda for reproductive health services in Pakistan. 2003. conflict settings. Soc Sci Med 1999, 49:1689-1703. 18. Women’s Refugee Commission: Life-Saving 7. Inter-agency Working Group on Reproductive Reproductive Health Care in Chad: Ignored and Health in Crises: Report of an Inter-agency Global Neglected. 2004. Evaluation of Reproductive Health Services for 19. Women’s Refugee Commission: Reproductive Refugees and Internally Displaced Persons. Geneva; Health in an Emergency: Assessment of the 2004. Minimum Initial Service Package in Tsunami- 8. Sphere Project: Humanitarian Charter and Affected Areas in Indonesia. 2005. Minimum Standards in Disaster Response. Geneva; 20. Women’s Refugee Commission: Reproductive 2011. Health Coordination Gap, Services Ad Hoc: 9. World Health Organization: IASC Health Cluster Minimum Initial Service Package (MISP) in Kenya. Guide: A Practical Guide for Country-Level 2008. Implementation of the Health Cluster. Geneva; 21. CARE, International Planned Parenthood 2009. Foundation, Save the Children, Women’s Refugee

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Commission: Priority Reproductive Health Activities post emergency phase camps. JAMA 2002, in Haiti: An Inter-agency MISP Assessment. 2011. 288:595-603. 22. UNFPA: State of the World Population 1999. 1999. 35. Women’s Refugee Commission: Universal and 23. Lehmann A: Safe abortion: a right for refugees? adaptable information, education & communication Reprod Health Matter 2002, 10:151-155. (IEC) templates on the MISP [http://iawg.net/iec- misp/]. 24. McGinn T: Reducing death and disability from unsafe abortion. In Routledge Handbook of Global 36. Ramalingam B: Aid on the Edge of Chaos. Oxford: Public Health. New York: Routledge;Parker R, Oxford University Press; 2013. Sommer M 2011:191-198. 37. UN Office for the Coordination of Humanitarian 25. Levine R, Langer A, Birdsall N, Matheny G, Wright Affairs: Humanitarianism in the network age. New M, Bayer A: Contraception. In Disease Control York; 2013. Priorities in Developing Countries. 2 edition. New 38. WHO, UNHCR: Clinical management of rape York: Oxford University Press;Jamison DT, Mosley survivors: developing protocols for use with WH, Measham AR, Bobadilla JL 2006:1193-1209. refugees and internally displaced persons. 26. Ross J, Hardee K, Mumford E, Eid S: Contraceptive Geneva; 2004. method choice in developing countries. Int Fam Plan Perspect 2002, 28:32-40. Endnotes a Formerly known as the Inter-agency Working Group 27. Inter-agency Working Group on Reproductive for Reproductive Health in Refugee Situations Health in Crises: A Statement on Family Planning b for Women and Girls as a Life-Saving Intervention The MISP is a set of priority activities designed to in Humanitarian Settings. 2010. ensure coordination, prevent sexual violence and provide care for survivors, prevent maternal and 28. London School of Hygiene and Tropical Medicine, neonatal morbidity and mortality, and HIV Harvard School of Health, Overseas Development transmission, and plan for comprehensive Institute: An Evidence Review of Research on Health reproductive health services. Additional priorities Interventions in Humanitarian Crises. 2013. include ensuring the availability of contraceptives 29. Patel P, Roberts B, Guy S, Lee-Jones L, Conteh L: to meet demand, syndromic treatment of STIs, Tracking official development assistance for anti-retrovirals for continuing users, and menstrual reproductive health in conflict-affected countries. hygiene supplies. PLoS Med 2009, 6:e1000090. c Formerly known as the Reproductive Health for 30. Inter-Agency Standing Committee: Guidelines for Refugees Consortium, the RHRC Consortium is Addressing HIV in Humanitarian Settings. 2010. comprised of the American Refugee Committee, 31. Tanabe M, Schlecht J, Manohar S: Adolescent CARE, Columbia University, International Rescue Sexual and Reproductive Health Programs in Committee, JSI Research and Training Institute, Humanitarian Settings: An In-depth Look at Family Marie Stopes International, and the Women’s Planning Services. Women’s Refugee Commission Refugee Commission. 2011. d Health centers should provide basic emergency 32. Hynes M, Sakani O, Spiegel P, Cornier N: obstetric and newborn care, which includes: A study of refugee maternal mortality in 10 1. administering parenteral antibiotics; countries 2008-2010. Int Perspect Sex Reprod 2. administering uterotonic drugs; 3. administering Health 2012, 38:205-13. parenteral anticonvulsants (e.g., magnesium sulphate); 4. performing manual removal of placenta; 33. O’Heir J: Pregnancy and childbirth care following 5. performing removal of retained products of conflict and displacement: care for refugee women conception (e.g., manual vacuum aspiration); in low-resource settings. J Midwifery Wom Heal 6. performing assisted vaginal delivery (e.g., vacuum 2004, 49(Suppl 1):14-18. extraction); 7. performing neonatal resuscitation 34. Hynes M, Sheik M, Wilson HG, Spiegel P: (with bag and mask). Hospitals should provide Reproductive health indicators and outcomes comprehensive emergency obstetric and newborn among refugee and internally displaced persons in

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care, which includes the seven functions outlined above as well as: 8. performing blood transfusion; and 9. performing surgery (e.g., Caesarean section). e The selected elements of clinical management of rape assessed were the availability of emergency contraception, post-exposure prophylaxis for HIV, and antibiotics for prevention of sexually transmitted infections; the provision of these drugs in the previous three months; and at least one staff trained to provide clinical management of rape. The full minimum package of clinical management of rape for low-resource settings includes 25 elements [38].

doi:10.1186/1752-1505-9-S1-I1 Cite this article as: Chynoweth: Advancing reproductive health on the humanitarian agenda: the 2012-2014 global review. Conflict and Health 2015 9(Suppl 1):I1.

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RESEARCH Open Access Evaluations of reproductive health programs in humanitarian settings: a systematic review

Abstract Provision of reproductive health (RH) services is a minimum standard of health care in humanitarian settings; however access to these services is often limited. This systematic review, one component of a global evaluation of RH in humanitarian settings, sought to explore the evidence regarding RH services provided in humanitarian settings and to determine if programs are being evaluated. In addition, the review explored which RH services receive more attention based on program evaluations and descriptive data. Peer-reviewed papers published between 2004 and 2013 were identified via the Ovid MEDLINE database, followed by a PubMed search. Papers on quantitative evaluations of RH programs, including experimental and non-experimental designs that reported outcome data, implemented in conflict and natural disaster settings, were included. Of 5,669 papers identified in the initial search, 36 papers describing 30 programs met inclusion criteria. Twenty-five papers described programs in sub-Saharan Africa, six in Asia, two in Haiti and three reported data from multiple countries. Some RH technical areas were better represented than others: seven papers reported on maternal and newborn health (including two that also covered family planning), six on family planning, three on sexual violence, 20 on HIV and other sexually transmitted infections and two on general RH topics. In comparison to the program evaluation papers identified, three times as many papers were found that reported RH descriptive or prevalence data in humanitarian settings. While data demonstrating the magnitude of the problem are crucial and were previously lacking, the need for RH services and for evaluations to measure their effectiveness is clear. Program evaluation and implementation science should be incorporated into more programs to determine the best ways to serve the RH needs of people affected by conflict or natural disaster. Standard program design should include rigorous program evaluation, and the results must be shared. The papers demonstrated both that RH programs can be implemented in these challenging settings, and that women and men will use RH services when they are of reasonable quality.

Introduction for refugees [1]. The groundbreaking report Increased attention to the reproductive Refugee Women and Reproductive Health Care: health (RH) needs of people affected by Reassessing Priorities highlighted how the health armed conflict or natural disaster began in of refugee women fleeing war was further the mid-1990s with a few key events. The threatened by near absence of reproductive Lancet published an editorial identifying health services [2]. The 1994 International family planning as a complete gap in services Conference on Population and Development in Cairo specifically recognized the rights of Correspondence: [email protected] Heilbrunn Department of Population and Family Health, Mail- displaced populations to RH [3]. This led to man School of Public Health, Columbia University, 60 Haven the formation in 1995 of the Inter-Agency Ave, New York, NY 10032, USA

@ 2015 Casey; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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. 17 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

Working Group on RH in Crisis (IAWG), Methods a consortium of non-governmental Search strategy organizations (NGO), donors and United This literature review summarized peer- Nations (UN) agencies, to advance RH reviewed papers published since the last services in humanitarian settings. In 1999, global evaluation (between 2004 and 2013) the IAWG developed the Inter-Agency field that were identified via the Ovid MEDLINE manual on reproductive health in humanitarian database, followed by a PubMed search to settings to provide technical and program pick up more recent papers not currently guidance to field staff [4]. In 2004, the indexed. In addition, references for included IAWG completed a global evaluation of RH papers were cross-checked to ensure that all in humanitarian settings at field, agency and relevant literature was identified and global levels. The evaluation found that more included. A combination of terms describing RH services were available conflict and natural disasters were used with than a decade earlier, although major gaps terms describing RH under the broad remained in most of the technical areas, with categories from the Inter-agency field manual on gender-based violence as the least developed reproductive health in humanitarian settings of technical area. Although RH services were maternal and newborn health, family somewhat more available for refugees living planning (FP), gender-based violence (GBV), in camps, they were largely absent for HIV/AIDS and other sexually transmitted internally displaced (IDP) and non-camp infections (STIs), safe abortion and populations [5]. Adolescents were adolescent reproductive health. Searches underserved, and safe abortion was not even were limited to papers published in English. assessed. The global evaluation identified a This initial search was broad and intended to need to improve RH data collection to capture all papers on RH in humanitarian ensure that useful data were collected and settings. Papers on quantitative evaluations properly interpreted, as well as for more of RH programs, including experimental and rigorous program evaluations. non-experimental designs that reported From 2012-2014, another ten years on, outcome the IAWG conducted a second global data were included. Descriptive quantitative evaluation of RH in humanitarian settings. studies with no specific health intervention This systematic review, one component of identified and no outcomes or outputs the 2014 global review, sought to explore the reported (e.g., studies that reported only evidence regarding RH services provided in descriptive or baseline data) as well as purely humanitarian settings. Are RH programs in qualitative papers were excluded. Studies these settings being evaluated? Do the were not excluded on the basis of their programs work? What is the quality of the quality. Other inclusion and exclusion criteria evaluations? Which RH services receive are detailed in Table 1. Papers excluded more programmatic and financial attention under these criteria but that reported based on program evaluations and descriptive or prevalence data were logged to descriptive data? permit comparison of the sectoral spread of

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Table 1 Inclusion/exclusion criteria

Included Excluded Topic Papers that described RH programs to address maternal and Papers that reported on other reproductive health topics (e.g., newborn health, FP, HIV and other STIs and/or GBV (sexual female genital mutilation, forced or early marriage, reproductive violence including rape, sexual abuse and sexual exploitation, and cancers) intimate partner violence) Types of Quantitative evaluations of RH programs or services, including Descriptive quantitative papers with no specific health Papers/ experimental and non-experimental designs that report outcome intervention and no outcomes (e.g., reporting only descriptive or Data data baseline data); purely qualitative papers Settings Humanitarian crises in conflict, post-conflict or natural disaster Papers in locations that were not affected by armed conflict or settings in lower or middle income countries natural disaster; that were more than ten years post-conflict; disaster settings in higher income countries Types of Papers in peer-reviewed journals Letters, editorials, commentaries; grey literature; review papers publications (although these were screened for references) Language English Study titles and abstracts in languages other than English Publication January 2004 – December 2013 Papers published before 2004 or after 2013 date

evaluation papers (the focus here) and (including two that also covered FP), six on broader prevalence or descriptive papers. FP, three on GBV, 20 on HIV and other STIs and two on general RH topics (Table 2). Quality assessment of the papers None of the papers described safe abortion The quality of each included study was or post-abortion care programs, and five of assessed using criteria from the STROBE the papers described HIV prevention checklist for observational studies or the programs targeting adolescents. Only six CONSORT checklist for clinical trials [6,7]. papers were classified as high quality while Papers were assigned a rating of high, the majority was classified as medium quality medium or low quality based on the number or low quality. Fewer than half (16) of the of met criteria in a list adapted from these papers reported comparison data, either in checklists. the form of pre- and post-intervention measures or intervention and comparison Results groups. Table 3 provides a summary of the The search strategy yielded 5,669 papers after included papers. duplicates were removed; 5,310 were Of the 323 papers reviewed and excluded based on a review of the title. Of excluded, 93 papers reported descriptive or the 359 papers for which abstract or fulltext review was conducted, 323 papers were excluded, leaving 36 papers describing 30 programs (Figure 1). Of the 36 papers, 25 described programs in sub-Saharan Africa, six in Asia, two in Haiti and three reported data from multiple countries and continents. Some RH technical areas were better represented than others: seven papers reported on maternal and newborn health Figure1 Systematic review flow chart

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prevalence data on RH in crisis settings. elements of basic EmONC plus blood Again, some RH technical areas were better transfusion and ANC in eastern Burma [11]; represented than others: 20 papers on seconding refugee health workers to health maternal and newborn health (including one facilities serving the refugee population and that also reported on FP and one that also training refugee women to promote RH in looked at GBV), four on FP, 32 on GBV, 27 the community in Guinea [12]; and training on HIV or other STIs (only six of which CHWs in Afghanistan to strengthen the link mentioned other STIs), seven papers on between the community and formal health general RH and five on adolescent RH services [13]. All three papers reported (specifically HIV, GBV or FP) (Table 2). increased use of skilled birth attendants postintervention. The Afghanistan study, Maternal and newborn health however, found that only the presence of a Seven of the 36 papers described evaluations female CHW was associated with increased of maternal and newborn health programs, skilled birth attendance; the association was including two programs that also addressed absent with male CHWs. One paper family planning. The papers covered a range assessing the effectiveness of baby tents of topics including emergency obstetric and (clean spaces to support mothers to practice newborn care (EmONC), antenatal care healthy infant feeding) established in Haiti (ANC) and the training of traditional birth found that 70% of babies less than six attendants or community health workers months old were exclusively breastfed and (CHWs) to improve maternal health 10% of non-exclusively breastfed infants outcomes. moved to exclusive breastfeeding while Two papers described the outcomes of enrolled [14]. Finally, an evaluation of a programs to improve EmONC services, the home-based lifesaving skills training for first for Afghan refugees in Pakistan [8] and traditional midwives in Liberia found that the second in humanitarian settings in nine midwives’ knowledge improved from pre to countries [9]. Although not all supported post training and remained stable one year facilities met the WHO criteria of fully later [15]. functional EmONC facilities [10], the papers reported greater availability post-intervention Family planning (FP) of EmONC services 24 hours a day and Six papers described FP programs, including subsequent increased use of those services two that also described maternal and in most facilities. The authors of both papers newborn health outcomes. Programs used described challenges in calculating the UN different strategies to improve FP use: process indicators for EmONCa at baseline providing the full range of FP methods, [10], primarily due to the absence of key data including longacting and permanent from delivery registers; however, both methods, via mobile clinics and reported these indicators at endline. strengthening health centers’ provision of Other program approaches to improve short- and long-acting FP in northern maternal and newborn health involved Uganda [16]; training mobile health workers training mobile health workers to provide to provide short-acting methods in eastern 20 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

Table 2 Number of papers by RH technical component Number (%) of program evaluation papers (n=36*) Number (%) of descriptive papers for comparison (n=93*) Maternal and newborn health 7 (19%) 20 (22%) Family planning 6 (17%) 4 (4%) Gender-based violence 3 (8%) 32 (34%) HIV and other STIs 20 (56%) 27 (29%) Adolescent RH 5 (14%) 5 (5%) General RH 2 (6%) 7 (8%) *The sum of the RH components is greater than the total number of papers as some papers reported on multiple components.

Burma [11]; seconding refugee providers to months after treatment compared to those in health facilities serving refugees to provide the control group [20]. The second paper FP and training female CHWs to promote found that the global functioning of FP use in Guinea [17]; and training CHWs survivors in the Republic of Congo to conduct FP education and provide short improved following post-rape psychological acting methods in Afghanistan [18]. All four care, and improvement was maintained one papers reported that contraceptive to two years later although high loss to follow prevalence increased from baseline or was up weakened these results [21]. The third higher than national levels. Additional papers paper reviewed the effects of a multi-media found that the presence of a female CHW training tool for clinical care for rape was associated with higher FP use in survivors on the knowledge, attitudes and Afghanistan [13], and that contraceptive use practices of health providers in four conflict was higher among Afghan refugee women in settings [22]. The authors found that Pakistan who received subsidized health although negative attitudes towards survivors services than among those with access to un- did not significantly change, respect for subsidized services [19]. patient rights increased and provider practice improved from pre-training to three months Gender-based violence (GBV) post-training. Although the literature search included broader terms related to GBV, all three HIV and other sexually transmitted included papers focused specifically on care infections (STIs) for survivors of rape. Two papers reviewed More papers (20) focused on HIV and other the effectiveness of psychosocial STIs than any other RH component; interventions for survivors. A randomized however only three of these reported on controlled trial in the Democratic Republic STIs other than HIV. Three papers reported of the Congo (DRC) on the effectiveness of results of retrospective record reviews to group cognitive processing therapy versus evaluate programs to prevent mother to child individual support to female survivors of transmission of HIV (PMTCT), two in rape found that those who received group northern Uganda and one in a refugee camp psychotherapy showed greater improvement in Tanzania. One program found that higher in depression, anxiety and post-traumatic proportions of HIV-positive pregnant stress disorder (PTSD) symptoms six women identified in ANC used anti- 21 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

retroviral prophylaxis in northern Uganda papers reported on a group randomized compared with the national average [23]. The controlled trial to evaluate the impact of an other two programs reported high numbers evidencebased HIV prevention intervention lost to follow-up before completing infant on sexual risk behaviors of in-school 6th HIV testing at 18 months. In one study, this graders in Liberia [35,36], and six used post- was primarily due to a lack of understanding intervention surveys to assess program of its importance and infant death; effectiveness in four African countries [37- incomplete or no ARV prophylaxis, early 42]. All of the papers reported mixed results weaning and prolonged breastfeeding were of their prevention programs regarding associated with increased risk of loss to some elements of knowledge and behavior follow-up and infant death [24]. In the final change; however, the four that follow study, more than two-thirds of the reported more positive results. A comparison HIVinfected women were repatriated to their of pre- and post-intervention survey data in home country before delivery; among those Sierra Leone found that HIV-related who delivered in the camp, nevirapine uptake knowledge and condom use increased was 98% [25]. among adolescents [37], commercial sex Eight papers reported the outcomes of workers and military personnel [38] following anti-retroviral therapy (ART) programs for an HIV prevention program including HIV-positive adults or children in East intensive IEC activities and distribution of Africa, Haiti and globally. Three papers free condoms. Two papers on refugee camps found that ART patients in northern Uganda in Guinea reported that exposure to program had mortality rates and adherence peer educators was associated with improved comparable to or better than ART patients HIV and STI knowledge and changed in stable settings or who were not displaced behavior to prevent HIV [39,40]. [26-28]. Similarly, a review of the data from 24 ART programs in conflict or post-conflict General RH settings found that patient outcomes were Two papers reported on unique efforts comparable to those in stable settings [29]. related to reproductive health. A program to Five papers examined the effect of a crisis improve and measure the quality of RH on ART programs: the post-election violence services at a clinic serving Burmese refugees in Kenya in early 2008 [30-32], acute conflict and migrant workers on the Thailand-Burma in DRC in 2004 [33] and the earthquake in border improved the quality of care, and also Haiti in 2010 [34]. Notably, although the increased staff skills and motivation to papers found higher rates of treatment collect and use data to make program interruption immediately post-disaster, decisions [43]. An evaluation of a literacy generally services were quickly re-established program that used RH content in Guinea and patient attendance and adherence found that refugee women who completed rebounded soon after. the program reported high knowledge on Eight papers reported HIV and/or STI maternal and newborn health, HIV and knowledge, attitudes and behavior results STIs; increased use of FP; and a marked following HIV prevention programs. Two increase in feelings of empowerment [44]. 22 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

Discussion evaluations, one-third (32) of the descriptive This review found that some RH programs papers reported prevalence and types of in crisis settings have been evaluated sexual violence perpetrated in humanitarian although most evaluations were medium in settings. This suggests that GBV does, in quality, suggesting limitations in study design fact, receive attention in research, although and analysis. Most of the papers reported perhaps less in programming which when generally positive results suggesting that implemented may be only rarely evaluated. these programs are likely well-designed and FP, on the other hand, was under- reasonably well-implemented. The papers represented among both program demonstrated both that RH programs can be evaluations and descriptive papers suggesting implemented in these challenging settings that FP overall receives less attention than and that women and men will use RH the other RH components. Adolescents services when they are of reasonable quality. often face additional barriers to meeting their In comparison to the program evaluation RH needs [48], but only four HIV papers identified, three times as many papers prevention programs targeted adolescents were found that reported RH descriptive or and no papers evaluated adolescent-friendly prevalence data in humanitarian settings. RH services. No papers mentioned safe While data demonstrating the magnitude of abortion which remains virtually unavailable the problem are crucial and were previously in humanitarian settings [49], nor post- lacking, the need for RH services and for abortion care. evaluations to measure their effectiveness is Programs requiring long-term follow-up clear [45,46]. It is critical to more directly link faced specific challenges introduced by the research to interventions and increase the instability of crisis settings and associated evidence base for RH service delivery population movements. Some of these strategies in humanitarian settings. This challenges, such as brief interruptions to includes not only the research but also treatment that arose during incidents of publication and sharing of results. An crisis, can and should be managed or increased focus on implementation science prevented with planning, as demonstrated in is needed to explore how best to improve the response to post-election violence in delivery and use of RH services as well as the Kenya [30,32] and an upswing in violence in use of research to improve practice [47]. DRC [33]. Training refugee or IDP health Although published articles are not workers, who would likely move with their representative of RH programs implemented community, may be a potential strategy for in humanitarian settings as most programs ensuring continued access to care for do not publish their results, they may reflect displaced people after they return home. relative attention, both programmatic and Additional challenges to the implementation financial, to particular areas. A of RH programs were identified in the preponderance of papers reported on papers. For example, highly trained health HIV/AIDS programs although few workers are needed to provide RH services, mentioned other STIs. While GBV was and they may require updated competency- under-represented among program based training, particularly for EmONC, 23 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

longacting and permanent FP and clinical it is crucial that these programs be care for survivors of rape. The evaluation of implemented, rigorously evaluated and a training tool for providers suggested that published. Further, it would be useful for although attitudes are challenging to change, programs (and journals) to publish results of care for survivors of rape can be improved programs that were unsuccessful so others [22]. may learn from those experiences. Proven evidenced-based strategies Fewer than half of the papers used any should be adapted and implemented in kind of comparison, either between pre- and humanitarian settings. For example, post- measures or between intervention and EmONC is crucial to reduce maternal comparison groups. This is not a call for morbidity and mortality, and is thus a more randomized controlled trials, however, component of the minimum standard in since randomizing clients is not often humanitarian RH service delivery (the appropriate, due to the fundamental principle Minimum Initial Service Package) [4]. Yet, of client choice in FP and GBV only three of the seven maternal and programming [54]. Evaluations using pre- newborn health programs that were and post-intervention measures or quasi- evaluated aimed to improve the availability experimental designs may be appropriate, of these critical services. Only one of the particularly where a program strategy is evaluated programs improved the availability implemented in phases and a group that has of long-acting or permanent FP methods; not yet received the intervention serves as a the other programs were generally limited to comparison for a group in an earlier phase short-acting methods, despite evidence that of the program. In addition, the challenges a broad choice of methods is an essential to collecting data in humanitarian settings are component of good FP programming and well-recognized [55,56], and population- also associated with increased use [50-52]. based surveys may be particularly challenging Although a foundation in social change in these unstable and insecure settings [57]. theory has been shown to be important for Therefore, other rigorous measures of behavior change [53], only one of the HIV program quality that are feasible to collect prevention programs appears to have had should be explored. For example, the UN such a base [35,36]. Behavior change process indicators of EmONC were communication efforts implemented in developed to monitor interventions proven humanitarian settings should adapt such to reduce maternal mortality without the proven evidence-based strategies. Moreover, limitations and expense of a maternal it is critical that best practices be shared mortality survey by using information across the humanitarian and development available at health facilities [10,58]. What fields. While the humanitarian field has similar practical approximations could be adapted strategies that have been successful used to measure the success of FP and GBV in development settings for many RH programs? It is plausible that evaluations of components, response to sexual violence is clinical HIV programs were in the majority one area where the humanitarian field may because program quality could be measured be in advance of the development field, and using clinical data (patient adherence and 24 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

outcomes) that were routinely collected. List of abbreviations used Challenges to collecting appropriate data ANC: antenatal care; ART: anti-retroviral therapy; have been noted [5,9]; increased effort CHW: community health worker; DRC: Democratic Republic of the Congo; EmONC: should be put into routine data collection to emergency obstetric and newborn care; FP: ensure that good quality data to measure family planning; GBV: gender-based violence; standard indicators are collected, and shared. IAWG: Inter-Agency Working Group on This may mean adapting registers to capture Reproductive Health in Crisis; NGO: nongovernmental organization; PMTCT: data on, for example, obstetric complications prevention of mother to child transmission of or to record new, continuing and switching HIV; PTSD: post-traumatic stress disorder; RH: FP clients. Reproductive health; STIs: sexually transmitted Limitations of this review include its infections; UN: United Nations.

restriction to quantitative methodologies and Competing interests to papers published in English, which may The author declares that she has no competing have excluded relevant publications. The interests. selected search parameters may have missed papers that did not explicitly refer to conflict Authors’ information The author is a member of the Steering or humanitarian settings or natural disasters, Committee of the Inter-Agency or the general RH topics that were searched Working Group on RH in Crises. in the title, abstract or key words. While the included papers may be representative of Acknowledgements I gratefully acknowledge the valuable support peer-reviewed published literature, they are and advice of Therese McGinn throughout the not representative of RH programming in review. humanitarian settings: humanitarian agency staff may not have time to write up results Declarations This article has been published as part of Conflict for publication and negative or null findings and Health Volume 9 Supplement 1, 2015: Taking may be difficult to publish. Stock of Reproductive Health in Humanitarian Program evaluation and implementation Settings: 2012-2014 Inter-agency Working Group science should be incorporated into on Reproductive Health in Crises’ Global Review. programs to determine the best ways to serve The full contents of the supplement are available online at http://www.conflictandhealth.com/ the RH needs of people affected by conflict supplements/9/S1. Funding for this supplement or natural disaster. Standard program design was provided by the MacArthur Foundation. should include rigorous program evaluation [59] and improved routine data collection. Published: 2 February 2015 The results must be shared so that proven evidence-based strategies for RH are References implemented in humanitarian settings. These 1. Reproductive freedom for refugees. The Lancet papers demonstrated both that RH programs 1993, 341:929-930. can be implemented in these challenging 2. Wulf D: Refugee Women and Reproductive Health Care: Reassessing Priorities. New York: Women’s settings, and that women and men will use Commission for Refugee Women and Children; RH services when they are of reasonable 1994 [http://www.womensrefugeecommission.org/ quality. resources/document/583-refugee-women-and- reproductive-health-care-reassessingpriorities]. 25 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

3. Programme of Action of the International Guinea III: maternal health. Conflict and health Conference on Population and Development. Cairo; 2011, 5:5. 1994 [http://www.un.org/popin/icpd/conference/ 13. Viswanathan K, Hansen PM, Rahman MH, offeng/poa.html]. Steinhardt L, Edward A, Arwal SH, Peters DH, 4. Inter-agency Working Group on Reproductive Burnham G: Can community health workers Health in Crises: Inter-agency field manual on increase coverage of reproductive health services? reproductive health in humanitarian settings. Journal of epidemiology and community health Geneva; 2010 2012, 66:894-900. [http://www.iawg.net/resources/field_manual.html]. 14. Ayoya MA, Golden K, Teta IN, Moreaux M, 5. Inter-Agency Working Group on Reproductive Mamadoultaibou A, Koo L, Boyd E, Beauliere JM, Health in Refugee Situations: Report of an Inter- Lesavre C, Marhone JP: Protecting and improving Agency Global Evaluation of Reproductive Health breastfeeding practices during a major emergency: Services for Refugees and Internally Displaced lessons learnt from the baby tents in Haiti. Bulletin Persons. Geneva; 2004 of the World Health Organization 2013, 91:612- [http://www.iawg.net/resources/2004_global_eval]. 617. 6. von Elm E, Altman DG, Egger M, Pocock SJ, 15. Lori JR, Majszak CM, Martyn KK: Home-based life- Gøtzsche PC, Vandenbroucke JP, for the SI: The saving skills in Liberia: acquisition and retention of Strengthening the Reporting of Observational skills and knowledge. Journal of midwifery & Studies in Epidemiology (STROBE) Statement: women’s health 2010, 55:370-377. Guidelines for Reporting Observational Studies. 16. Casey SE, McNab SE, Tanton C, Odong J, Testa AC, PLoS medicine 2007, 4:e296. Lee-Jones L: Availability of long-acting and 7. Schulz KF, Altman DG, Moher D, for the CG: permanent family-planning methods leads to CONSORT 2010 Statement: Updated Guidelines for increase in use in conflict-affected northern Reporting Parallel Group Randomised Trials. PLoS Uganda: Evidence from cross-sectional baseline and medicine 2010, 7:e1000251. endline cluster surveys. Global public health 2013, 8. Purdin S, Khan T, Saucier R: Reducing maternal 8:284-297. mortality among Afghan refugees in Pakistan. 17. Howard N, Kollie S, Souare Y, von Roenne A, International journal of gynaecology and obstetrics Blankhart D, Newey C, Chen MI, Borchert M: 2009, 105:82-85. Reproductive health services for refugees by 9. Krause SK, Meyers JL, Friedlander E: Improving the refugees in Guinea I: family planning. Conflict and availability of emergency obstetric care in conflict- health 2008, 2:12. affected settings. Global public health 2006, 18. Huber D, Saeedi N, Samadi AK: Achieving success 1:205-228. with family planning in rural Afghanistan. Bulletin 10. WHO, UNFPA, UNICEF, Averting Maternal Death of the World Health Organization 2010, 88:227- and Disability Program Columbia University: 231. Monitoring emergency obstetric care: a handbook. 19. Raheel H, Karim MS, Saleem S, Bharwani S: Geneva: World Health Organization; 2009 Knowledge, attitudes and practices of [http://www.who.int/reproductivehealth/ contraception among Afghan refugee women in publications/monitoring/9789241547734/en/]. Pakistan: a cross-sectional study. PloS one 2012, 11. Mullany LC, Lee TJ, Yone L, Lee CI, Teela KC, Paw P, 7:e48760. Shwe Oo EK, Maung C,Kuiper H, Masenior NF, 20. Bass JK, Annan J, McIvor Murray S, Kaysen D, Beyrer C: Impact of Community-Based Maternal Griffiths S, Cetinoglu T, Wachter K, Murray LK, Health Workers on Coverage of Essential Maternal Bolton PA: Controlled Trial of Psychotherapy for Health Interventions among Internally Displaced Congolese Survivors of Sexual Violence. New Communities in Eastern Burma: The MOM Project. England Journal of Medicine 2013, 368:2182- PLoS medicine 2010, 7:e1000317. 2191. 12. Howard N, Woodward A, Souare Y, Kollie S, 21. Hustache S, Moro MR, Roptin J, Souza R, Gansou Blankhart D, von Roenne A, Borchert M: GM, Mbemba A, Roederer T, Grais RF, Gaboulaud Reproductive health for refugees by refugees in V, Baubet T: Evaluation of psychological support for 26 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

victims of sexual violence in a conflict setting: 30. Pyne-Mercier LD, John-Stewart GC, Richardson BA, results from Brazzaville, Congo. Int J Ment Health Kagondu NL, Thiga J, Noshy H, Kist N, Chung MH: Syst 2009, 3:7. The consequences of post-election violence on 22. Smith J, Ho L, Langston A, Mankani N, Shivshanker antiretroviral HIV therapy in Kenya. AIDS care 2011, A, Perera D: Clinical care for sexual assault survivors 23:562-568. multimedia training: a mixed-methods study of 31. Vreeman RC, Nyandiko WM, Sang E, Musick BS, effect on healthcare providers’ attitudes, Braitstein P, Wiehe SE: Impact of the Kenya post- knowledge, confidence, and practice in election crisis on clinic attendance and medication humanitarian settings. Conflict and health 2013, adherence for HIV-infected children in western 7:14. Kenya. Conflict and health 2009, 3:5. 23. Bannink-Mbazzi F, Lowicki-Zucca M, Ojom L, 32. Yoder R, Nyandiko W, Vreeman R, Ayaya S, Gisore Kabasomi SV, Esiru G, Homsy J: High PMTCT P, Braitstein P, Wiehe S: Long-term impact of the program uptake and coverage of mothers, their Kenya postelection crisis on clinic attendance and partners and babies in Northern Uganda: medication adherence for HIV-infected children in Achievements and lessons learned over 10 years of western Kenya. J Acquir Immune Defic Syndr 2012, implementation (2002-2011). J Acquir Immune 59:199-206. Defic Syndr 2013. 33. Culbert H, Tu D, O’Brien DP, Ellman T, Mills C, Ford 24. Ahoua L, Ayikoru H, Gnauck K, Odaru G, Odar E, N, Amisi T, Chan K, Venis S, Medecins Sans F, et al: Ondoa–Onama C, Pinoges L, Balkan S, Olson D, HIV treatment in a conflict setting: outcomes and Pujades-Rodríguez M: Evaluation of a 5-year experiences from Bukavu, Democratic Republic of Programme to Prevent Mother-to-child Transmission the Congo. PLoS Medicine / Public Library of of HIV Infection in Northern Uganda. Journal of Science 2007, 4:e129. Tropical Pediatrics 2010, 56:43-52. 34. Walldorf JA, Joseph P, Valles JS, Sabatier JF, Marston 25. Rutta E, Gongo R, Mwansasu A, Mutasingwa D, BJ, Jean-Charles K, Louissant E, Tappero JW: Rwegasira V, Kishumbu S, Tabayi J, Masini T, Recovery of HIV service provision postearthquake. Ramadhani H: Prevention of mother-to-child AIDS and behavior 2012, 26:1431-1436. transmission of HIV in a refugee camp setting in 35. Atwood KA, Kennedy SB, Shamblen S, Tegli J, Tanzania. Global public health 2008, 3:62-76. Garber S, Fahnbulleh PW, Korvah PM, Kolubah M, 26. Garang PG, Odoi RA, Kalyango JN: Adherence to Mulbah-Kamara C, Fulton S: Impact of schoolbased antiretroviral therapy in conflict areas: a study HIV prevention program in post-conflict Liberia. among patients receiving treatment from Lacor AIDS Educ Prev 2012, 24:68-77. Hospital, Uganda. AIDS patient care and STDs 36. Atwood KA, Kennedy SB, Shamblen S, Taylor CH, 2009, 23:743-747. Quaqua M, Bee EM, Gobeh ME, Woods DV, Dennis 27. Kiboneka A, Nyatia RJ, Nabiryo C, Anema A, B: Reducing sexual risk taking behaviors among Cooper CL, Fernandes KA, Montaner JS, Mills EJ: adolescents who engage in transactional sex in Combination antiretroviral therapy in population post-conflict Liberia. Vulnerable children and youth affected by conflict: outcomes from large cohort in studies 2012, 7:55-65. northern Uganda. BMJ Clinical research ed; 2009, 37. Casey SE, Larsen MM, McGinn T, Sartie M, Dauda 338-b201. M, Lahai P: Changes in HIV/AIDS/STI knowledge, 28. Kiboneka A, Nyatia RJ, Nabiryo C, Olupot-Olupot P, attitudes, and behaviours among the youth in Port Anema A, Cooper C, Mills E: Pediatric HIV therapy Loko, Sierra Leone. Global public health 2006, in armed conflict. In AIDS. Volume 22. London, 1:249-263. England; 2008:1097-1098. 38. Larsen MM, Sartie MT, Musa T, Casey SE, Tommy J, 29. O’Brien DP, Venis S, Greig J, Shanks L, Ellman T, Saldinger M: Changes in HIV/AIDS/STI knowledge, Sabapathy K, Frigati L, Mills C: Provision of attitudes and practices among commercial sex antiretroviral treatment in conflict settings: the workers and military forces in Port Loko, Sierra experience of Medecins Sans Frontieres. Conflict Leone. Disasters 2004, 28:239-254. and health 2010, 4:12. 39. Chen MI, von Roenne A, Souare Y, von Roenne F, Ekirapa A: Reproductive health for refugees by 27 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

refugees in Guinea II: sexually transmitted 50. Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier infections. Conflict and health 2008, 2:1-7. A, Innis J: Family planning: the unfinished agenda. 40. Woodward A, Howard N, Souare Y, Kollie S, von Lancet 2006, 368:1810-1827. Roenne A, Borchert M: Reproductive health for 51. Ross J, Hardee K, Mumford E, Eid S: Contraceptive refugees by refugees in Guinea IV: Peer education Method Choice in Developing Countries. and HIV knowledge, attitudes, and reported International Family Planning Perspectives 2002, practices. Conflict and health 2011, 5:10. 28:32-40. 41. Ciccio L, Sera D: Assessing the knowledge and 52. Ross J, Stover J: Use of modern contraception behavior towards HIV/AIDS among youth in increases when more methods become available: Northern Uganda: A cross-sectional survey. Biornale analysis of evidence from 1982–2009. Global Italiano di Medicina Tropicale 2010, 15:29- Health: Science and Practice 2013, 1:203-212. 34[http://numat.jsi.com/Resources/Docs/NUMATAbs 53. Briscoe C, Aboud F: Behaviour change tract_Ciccio_vol15_1.pdf]. communication targeting four health behaviours in 42. Tanaka Y, Kunii O, Hatano T, Wakai S: Knowledge, developing countries: A review of change attitude, and practice (KAP) of HIV prevention and techniques. Social Science & Medicine 2012, HIV infection risks among Congolese refugees in 75:612-621. Tanzania. Health & place 2008, 14:434-452. 54. Habicht JP, Victora CG, Vaughan JP: Evaluation 43. Sullivan TM, Sophia N, Maung C: Using evidence to designs for adequacy, plausibility and probability of improve reproductive health quality along the public health programme performance and impact. Thailand-Burma border. Disasters 2004, 28:255- Int J Epidemiol 1999, 28:10-18. 268. 55. Ford N, Mills E, Zachariah R, Upshur R: Ethics of 44. McGinn T, Allen K: Improving refugees’ conducting research in conflict settings. Conflict reproductive health through literacy in Guinea. and health 2009, 3:7. Global public health 2006, 1:229-248. 56. Thoms O, Ron J: Public health, conflict and human 45. McGinn T: Reproductive Health of War-Affected rights: toward a collaborative research agenda. Populations: What Do We Know? International Conflict and health 2007, 1:11. Family Planning Perspectives 2000, 26:174-180. 57. Spiegel PB: Who should be undertaking population- 46. O’Heir J: Section 1: Review of literature. In based surveys in humanitarian emergencies? Emerg Reproductive health services for refugees and Themes Epidemiol 2007, 4:12. internally displaced persons: report of an inter- 58. McGinn T: Monitoring and evaluation of PMM agency global evaluation 2004 IAWG: UNHCR 2004 efforts: what have we learned? International [http://www.iawg.net/resources/2004_global_eval/ journal of gynaecology and obstetrics 1997, documents/REPORT/report-sec-1.pdf]. 59: S245-S251. 47. Madon T, Hofman KJ, Kupfer L, Glass RI: 59. Rossi PH, Lipsey WM, Freeman HE: Evaluation: A Implementation Science. Science 2007, 318:1728- systematic approach. Thousand Oaks, CA: SAGE;, 7 1729. 2004. 48. UNFPA, Save the Children: Adolescent sexual and reproductive health toolkit for humanitarian settings: A companion to the Inter-agency field Endnotes a manual on reproductive health in humanitarian The eight UN process indicators for EmONC were settings. New York: UNFPA; 2009 developed to monitor progress in the prevention of [http://www.unfpa.org/publications/adolescent- maternal and perinatal deaths: sexual-andreproductive-health-toolkit-humanitarian 1. Availability of EmONC: at least 5 EmONC facilities -settings]. (including at least one comprehensive facility) for 49. McGinn T: Reducing death and disability from every 500,000 population unsafe abortion. In Routledge Handbook of Global 2. Geographical distribution of EmONC facilities Public Health. New York: Routledge; Parker R, 3. Proportion of all births in EmONC facilities Sommer M 2011:191-198. 4. Met need for emergency obstetric care:

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proportion of women with major direct obstetric complications who are treated in EmONC facilities (acceptable level is 100%) 5. Caesarean sections as a proportion of all births (acceptable level between 5 and 15%) 6. Direct obstetric case fatality rate (acceptable level is less than 1%) 7. Intrapartum and very early neonatal death rate 8. Proportion of maternal deaths due to indirect causes in emergency obstetric care facilities

doi:10.1186/1752-1505-9-S1-S1 Cite this article as: Casey: Evaluations of reproductive health programs in humanitarian settings: a systematic review. Conflict and Health 2015 9(Suppl 1):S1.

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Table 2 Number of papers by RH technical component

Author Country Intervention Evaluation design Key findings Quality (Year) Maternal and newborn health Ayoya et al Haiti Established baby tents in five cities Program data review (February 70% of infants less than 6 months Low (2013) [14] to promote and sustain optimal 2010-June 2012) from nutritional old were exclusively breastfed. 10% infant feeding practices: cluster database (n=193 baby of “mixed feeders” less than 6 breastfeeding and nutrition tents) months changed to exclusive support, infant growth monitoring, breastfeeding while enrolled. assessment of nutritional status of mother-infant pairs and pregnant women Howard et al Guinea Seconded refugee health workers Cross-sectional post-intervention Higher odds of facility delivery for Medium (2011)1[12] to health facilities serving refugees, multi-stage cluster survey in those exposed to intervention provided free RH services and intervention area of women education activities (OR=2.03, 95% trained refugee women as lay (n=444) and men (n=445) of CI 1.23-3.01), formally educated health workers reproductive age (Liberian and (OR=1.93, 95%CI 1.05-3.92), or Sierra Leonean refugees) living in grand multipara (OR= 2.13, 95%CI one of 48 refugee camps in 1.21-3.75). No significant Guinea in 1999. differences found in maternal health knowledge or attitudes. Krause et al Global (9 Improved availability of basic and Pre and post intervention facility Increased availability of EmONC 24 Medium (2006) [9] countries) comprehensive EmONC services in assessments (n=31 health facilities) hours a day. CEmONC facilities 12 conflict affected settings in 9 increased from 3 facilities at countries, Jan 2001-Apr 2005 baseline to 10 at endline; BEmONC facilities increased from 2 at baseline to 10 at endline. The number of signal functions available increased in all 31 facilities. Lori et al Liberia Trained traditional midwives in Pre- & immediate post-training Mean scores in 4 topic areas: 1) Medium (2010) [15] maternal care using the home- assessments (n=412 traditional first actions, 2) post-partum based life-saving skills series in midwives), 1-year follow up hemorrhage 3) woman referral, 4) 2006 assessment (n=389) baby referral, improved from pre- to post-test and remained stable one year later (p<.001 for all 4 topics) Purdin et al Pakistan Established EmONC facilities, Program data review 2000-2007 Maternal mortality ratio improved Medium (2009) [8] trained Afghan refugee community from 291 per 100,000 live births in members on safe motherhood, 2000 to 102 in 2004. Case fatality linked primary health care with rate for obstetric education on danger signs of complications=0.2%. Skilled birth pregnancy and the importance of attendance increased from 5% in skilled birth attendance, and 1996 to 67% in 2007. Complete improved the health information ANC coverage increased from 49% system. in 2000 to 90% in 2006; post-natal coverage increased from 27% in 2000 to 85% in 2006. Maternal and newborn health and family planning Mullany et al Burma Trained community-based skilled Pre (2006) & post (2008) Use of modern FP methods High (2010) [11] health workers in basic EmONC, intervention cross-sectional two- increased from 24% to 45% (PRR evidence-based ANC and FP in stage cluster surveys in 1.88, 95%CI 1.63-2.17). Unmet need Shan, Mon, Karen, and Karenni intervention areas of ever married for FP decreased 35% (95%CI 28%- regions of Burma women of reproductive age: 40%). Skilled birth attendance n=2,889 at baseline, n=2,442 at increased from 5% to 49% endline (PRR=9.55, 95%CI 7.21-12.64). Viswanathan Afghanistan Deployed CHWs to promote use of Data derived from the Afghanistan Presence of female CHW in Medium et al (2012) RH services in community and at Health Survey 2006: multistage community is associated with [13] health facilities cluster survey in 29 provinces increased use of FP (OR=1.61, 95% (n=8,281 women) CI 1.21-2.15), ANC (OR=2.71, 95%CI 1.87-3.92) and skilled birth attendant at last delivery (OR=1.75, 95%CI 1.18-2.58). These associations were not significant with a male CHW.

30 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

Table 2 Number of papers by RH technical component (Continued)

Family planning Casey et al Northern Provided short-acting, long-acting Baseline (2007) and post- Current use modern FP methods High (2013) [16] Uganda and permanent FP methods via intervention (2010) cross-sectional increased from 7.1% to 22.6% mobile outreach teams and multi-stage cluster surveys in (OR=3.34, 95%CI 2.27-4.92); use of strengthened public health center intervention area of women of LAPM increased 1.2% to 9.8% provision of short and long acting reproductive age: n=905 at (OR=9.45, 95%CI 3.99-22.4). Unmet FP methods baseline, n=873 at endline need for FP decreased from 52.1% to 35.7% (OR=0.47, 95% CI 0.37- 0.60). Howard et al Guinea Refugee health workers seconded Cross-sectional post-intervention Approval of FP was high, but more Medium (2008)1[17] to health facilities provided free RH multi-stage cluster survey in than 40% had not discussed FP services and trained refugee intervention area of women with partner. Current use of women as lay health workers (n=444) and men (n=445) of modern FP (17%) was higher than reproductive age (Liberian and in country of origin (3.9%) or host Sierra Leonean refugees) living in country (4.1%). Perceived service one of 48 refugee camps in quality was most important Guinea in 1999. determinant in choice of where to get FP. Huber et al Afghanistan Improved access to FP using CHWs Baseline (2004) and endline (2006) Current FP use increased by 24- Low (2010) [18] and community-based distribution cross-sectional surveys using lot 27%, with injectables contributing of short acting methods quality assurance sampling; most to the increase. verification of FP use via home visits of 150 FP users per CHW Raheel et al Pakistan Provided subsidized or Cross-sectional study in 2008 using Refugee women receiving High (2012) [19] unsubsidized health care to Afghan systematic random sampling of 2 subsidized care were more likely to refugees in Karachi comparison groups: married have heard of FP (OR=10.12 95%CI Afghan women of reproductive 6.7-15.31) and currently use FP age receiving subsidized care (OR=3.65, 95%CI 2.61-5.10). (n=325) and unsubsidized care (n=325) Gender-based violence Bass et al Democratic Adapted group cognitive Random assignment of 16 villages 65% in intervention group and High (2013) [20] Republic of processing therapy (1 individual to intervention group (8) or 52% in control group completed the Congo session and 11 group sessions) individual support (8) for female all 3 measures. Improvements in all (DRC) provided by paraprofessionals sexual violence survivors in 2011 3 sets of symptoms were supervised by psychosocial staff significantly greater in therapy and clinical experts group than in individual support group. Mean scores for combined depression and anxiety improved significantly more in the therapy group compared to the individual support group (p<0.001 for all comparisons). Hustache et Republic of Provided medical care and Initial assessment January 2002- 56 women were evaluated using Medium al (2009) [21] Congo psychological support to women April 2003 (n=159 female survivors the Global Assessment of raped by an unknown perpetrator of rape); follow-up 1-2 years post- Functioning (GAF) scale at both in military clothing treatment, June-July 2004 (n=70) time periods, and global functioning significantly improved (p=.04); this improvement was maintained 1-2 years later Smith et al DRC, Multimedia training tool for health Assessment pre-training and 3 Although negative attitudes did Medium (2013) [22] Ethiopia, providers to encourage competent, months after, medical record not significantly decrease, respect Kenya, compassionate, and confidential review, in-depth interviews for patient rights increased (p<.05), Jordan clinical care for rape survivors (November 2010 to June 2012) and provider practice improved from before the training to 3 months post-training (p<.01). HIV/AIDS and other STIs Ahoua et al Northern PMTCT program including either Retrospective record review of all 53% of mother-infant pairs were Medium (2010) [24] Uganda short-course AZT or single dose mother-infant pairs enrolled July lost to follow-up before nevirapine and follow-up for 18 2000-July 2005 (n=517). Cross- completing infant testing at 18 months post-partum including sectional survey of infant status at months; the risk of death or being infant HIV testing 18 months following tracing of lost to follow-up was higher mother-infant pairs who were lost among infants with no or to follow up (n=327 women and incomplete intrapartum ARVs 368 babies). (OR=1.9, 95%CI 1.07–3.36) and of weaning before age 6 months (OR=2.55, 95%CI 1.42–4.58).

31 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

Table 2 Number of papers by RH technical component (Continued)

Atwood et al Liberia Evidence-based HIV prevention Attention-matched, group RCT: 4 The intervention significantly Medium (2012)3[35] curriculum adapted for in-school matched pairs of schools randomly improved protective peer norms Liberian youth. The 8-modules assigned to HIV prevention (p<.05) and positive condom promoted positive condom curriculum or general health attitudes (p<.05) at the 9 month attitudes and increased skills and curriculum. Students completed follow-up. Among those who were self-efficacy to refuse sex, negotiate baseline, immediate post-test, 3- sexually active at baseline, the condom use and use condoms and 9- month follow-up surveys to intervention group used condoms effectively. assess program efficacy (n=740 more consistently in the last 3 completed all measures) months (p<.05) at the 9-month follow-up. The intervention did not impact sexual initiation or multiple sex partnerships. Atwood et al Liberia Evidence-based HIV prevention Attention-matched, group RCT: 4 Risk behaviors for adolescents who Medium (2012)3[36] curriculum adapted for in-school matched pairs of schools randomly engaged in transactional sex were Liberian youth. The 8-modules assigned to HIV prevention no different in the intervention or promoted positive condom curriculum or general health control groups. attitudes and increased skills and curriculum. Students completed self-efficacy to refuse sex, negotiate baseline, immediate post-test, 3- condom use and use condoms and 9- month follow-up surveys to effectively. assess program efficacy (n=714 who responded to questions about transactional sex) Bannink- Northern PMTCT program including couple Retrospective record review of Of 140,658 women starting ANC, Medium Mbazzi et al Uganda VCT, care and treatment for HIV+ PMTCT program data 2002-2011 94.4% received HIV testing. Testing (2013) [23] individuals, home-based care, of male partners increased from partner involvement, follow-up at 5.9% in 2002 to 75.8% in 2011 18 months post-partum including (p=.001) compared to 15.5% infant HIV testing nationally. 79% of HIV+ women started ARVs, compared to 52% nationally. HIV prevalence among exposed infants tested by 18 months decreased from 10.3% in 2004 to 5.0% in 2011 (p=.001). Casey et al Sierra HIV/AIDS and STI prevention Baseline (2001) and post Respondents able to name 3 Medium (2006)2[37] Leone program comprised of intensive intervention (2003) cross-sectional effective means of avoiding AIDS outreach education by peers surveys using purposive quota increased from 4% to 36% among including a focus on improving sampling of youth: n=244 female, female youth and from 4% to 45% negotiation skills and distribution 293 male (baseline); n=250 female, among male youth; reported of free condoms targeting youth 299 male (endline) condom use at last sex increased from 16% to 46% (female) and from 16% to 37% (male) (p<.01 for all comparisons). Chen et al Guinea Refugee health workers seconded Cross-sectional post-intervention Self-reported STI symptoms were Medium (2008)1[39] to health facilities provided free RH multi-stage cluster survey in common: 30% among women and services and trained refugee intervention area of women 24% among men. Only 25% women as lay health workers (n=444) and men (n=445) of correctly named key STI symptoms. reproductive age (Liberian and Respondents citing program Sierra Leonean refugees) living in facilitators as sources of one of 48 refugee camps in information were more likely to Guinea in 1999. correctly name key STI symptoms (OR=5.2, 95% CI 1.9-13.9 (men)) and identify effective means of protecting against STIs (OR=2.9, 95% CI 1.5-5.8 (men)) and (OR=4.6, 95%CI 1.6-13.2 (women)). Ciccio and Northern HIV/AIDS prevention activities with Cross-sectional post-intervention 29% had comprehensive HIV Medium Sera (2010) Uganda youth including media campaigns, survey using lot quality assurance prevention knowledge (knew 3 [41] peer counseling, life skills training, sampling in intervention area main means of prevention and and activities for youth in (n=1,781 youth age 15-24) in 2008 rejected common misconceptions). particularly vulnerable 86% knew where to get tested for, circumstances to spread but only 51% had been tested and prevention messages and help received their result in the last 12 them develop the skills necessary months. Gender, geographical to protect themselves. location, marital status and education were associated with this knowledge (p<.001)

32 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

Table 2 Number of papers by RH technical component (Continued)

Culbert et al DRC Voluntary counseling and HIV Program data review: May 2002- 11,076 people received VCT, of Medium (2007) [33] testing (VCT), care and treatment Jan 2006 whom 19% were HIV+; 94% of for HIV+ individuals, HIV prevention these received follow-up care in activities the HIV clinics. 12-month mortality among ART patients was 7.9% (95%CI 3.6-12.1), and 12-month loss to follow-up was 5.4% (95%CI 3.2- 7.5), both comparable to stable low resource settings. Only 5 of 66 ART patients experienced treatment interruption during violent period of May-June 2004. Garang et al Northern Care and treatment for HIV+ Cross-sectional study using Mean 4-day adherence (self- High (2009) [26] Uganda individuals systematic sampling of self- reported) was 99.5%, with no reported adherence over 4-day difference between IDPs and non- period in February 2008 (n=200 IDPs. Being on a 1st line ART adults on ART) regimen (OR=22.2, 95%CI 1.5- 333.3), feeling facility staff were condemning (OR=22.2, 95%CI 1.5- 333.3), and lack of privacy at facility (OR=9.7, 95%CI 0.9-111.1) were associated with non-adherence. Kiboneka et Northern Care and treatment for HIV+ Prospective cohort study using Adherence was consistently Medium al (2008)4[28] Uganda individuals, facility and home-based program data June 2005 - Feb excellent in 92% of patients. No care, mobile clinics to IDP camps 2008 (n=57 HIV+ children receiving deaths and no major opportunistic combination ART) infections were recorded after initiation of ART. Kiboneka et Northern Care and treatment for HIV+ Prospective cohort study using The mortality incidence rate was Medium al (2009)4[27] Uganda individuals, facility and home-based program data, June 2005 - Jan 3.48 (95%CI 2.7-4.3) per 100 person care, mobile clinics to IDP camps 2008, (n=1,625 HIV+ adults years. Of patients with adherence receiving combination ART) data, 92% had adherence greater than 95%. 4.3% of patients died during follow-up, a mortality rate comparable to ART patients in stable settings. Lower mortality was associated with female sex, higher baseline CD4 count and ≥95% adherence. IDP camp residence and age were not associated with mortality outcomes. Larsen et al Sierra HIV/AIDS and STI prevention Baseline (2001) and post Those able to name 3 effective Medium (2004)2[38] Leone program comprised of intensive intervention (2003) cross-sectional means of avoiding AIDS increased outreach education by peers surveys using purposive quota from 5% to 70% among CSWs and including a focus on improving sampling: n=201 sex workers, 202 from 11% to 75% among military negotiation skills and distribution military men (baseline); n=202 sex men. Reported condom use at last of free condoms targeting workers, 205 military men (endline) sex increased from 38% to 68% commercial sex workers (CSW) and (CSW) and from 39% to 68% military men (military) (p<.01 for all). Although the proportions of both CSWs and military men who believe HIV+ people should be treated or counselled increased, the proportions believing they should be isolated or reported did not change. O’Brien et al Global Programs of care and treatment for Program data review 2005-2009 64% of ART patients remained on Medium (2010) [29] HIV+ individuals in conflict and (n=20 programs with complete ART, 10% died, 11% were lost to post-conflict settings data and n=4,145 HIV+ adults on follow-up. Median 12-month ART with complete data) mortality and loss to follow-up were 9% (95%CI 8.8-9.1) and 11% (95%CI 9-12) respectively. Median 6-month CD4 gain was 129 cells/ mm3.

33 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

Table 2 Number of papers by RH technical component (Continued)

Pyne-Mercier Kenya Care and treatment for HIV+ Retrospective record review for The odds of treatment interruption High et al (2011) individuals clients on ART during post-election were 71% (95%CI 34-118) higher [30] violence, Dec 30, 2007 - Feb 28, during the post-election violence 2008, and same time period 1 year period compared to 1 year earlier. earlier (n=2,534 HIV+ adults) Men (OR=1.4, 95%CI 1.1-1.8) and those traveling ≥3 hours to clinic (OR=1.9, 95%CI 1.3-2.7) were more likely to experience treatment interruption. Rutta et al Tanzania 2-year pilot PMTCT program in Program data review Oct 2002 - 92% of ANC clients were tested for Medium (2008) [25] refugee camp: community June 2004 (n=6 health facilities) HIV. 93% of HIV+ women agreed education, training providers, VCT, to take nevirapine at 34 weeks of infant feeding, counseling, gestation. 36% of the HIV+ women administration of nevirapine were repatriated before delivery, but 98% of those remaining took nevirapine at the start of labor and their infants received nevirapine within 72 hours. Only 15% of HIV- exposed infants were tested at 18 months due to repatriation, death or refusal of testing. Tanaka et al Tanzania HIV/AIDS prevention including Post-intervention survey of HIV risk increased after Medium (2008) [42] youth peer education, VCT, free systematically selected Congolese displacement due to increased condom distribution in Nyarugusu refugees of reproductive age transactional sex and forced sex refugee camp (n=570 male and 570 female) (p<.001). Condom use at last sex living in the refugee camp in 2005 with a non-regular partner was 14% and associated with citing the program health teams as a leading source of influence regarding HIV prevention Vreeman et Kenya Care and treatment for HIV- Retrospective cohort analysis of 93% of HIV-infected children Medium al (2009)5[31] infected children HIV+ children under 14 years seen returned to care in the 4 months from Oct-Dec 2007 in 18 clinics after the violence, and 98% of (n=2,585), and then followed from children on ART reported perfect Dec 2007 until April 2008. adherence during last 7 days (p<.001). Children on ART were more likely to return than those not on ART (OR=1.4, 95%CI 1.2-1.6). Orphan status and sex were not associated with return to clinic. Walldorf et Haiti HIV/AIDS clinical services including Program data Oct 2008-May 2010 Mean monthly enrollment for VCT, Medium al (2012) [34] VCT, PMTCT, care and treatment comparing pre-earthquake (prior to PMTCT and ART services were from for HIV+ individuals Dec 2009) to post-earthquake 41-46% of baseline levels in Jan outcomes (n=126 facilities) 2010 but rose to 79-89% of baseline levels in May 2010. Current ART patients rose 3.6% Jan – May 2010 compared to a 9.8% increase during the same period in 2009. Woodward Guinea Refugee health workers seconded Cross-sectional post-intervention HIV knowledge was high. Medium et al (2011)1 to health facilities provided free RH multi-stage cluster survey in Participants exposed to program [40] services and trained refugee intervention area of women peer education had higher odds of women as lay health workers (n=444) and men (n=445) of reporting changes in sexual reproductive age (Liberian and behavior to avoid HIV (OR=2.5, Sierra Leonean refugees) living in 95%CI 1.5-4.1). Exposed participants one of 48 refugee camps in were less likely to report staying Guinea in 1999. faithful (OR=0.6, 95%CI 0.4-0.9) and more likely to report fewer sex partners (OR=1.7, 95%CI 1.05-2.85). Yoder et al Kenya HIV/AIDS care and treatment for Retrospective cohort analysis for 3 Children on ART had less initial loss Medium (2012)5[32] HIV-infected children time periods: pre-election, Oct 26- to follow-up (p<.01) and less Dec 25 2007; immediately post- complete loss to follow-up election, Dec 26, 2007 - Apr 15, (p<.0001) than children not on 2008; and long-term post-election, ART. Immediately post-election, Apr 16-Dec 31, 2008 (n=2,549 HIV+ 8.2% of children on ART had children) imperfect medication adherence, and 9.0% long-term post-election.

34 Casey Conflict and Health 2015, 9(Suppl 1):S1 http://www.conflictandhealth.com/content/9/S1/S1

Table 2 Number of papers by RH technical component (Continued)

General RH McGinn & Guinea Literacy training using RH Post-intervention cross-sectional The proportion of women who Medium Allen (2006) information as the content and survey of RH literacy program reported communication with their [44] participatory adult education students who participated in 1999, partners on RH topics increased to techniques for Sierra Leonean and 2000 and 2001 RH literacy courses 87% (p<.001). Current use of FP Liberian women living in refugee and were still in the area in 2002 was 50%. The proportion of camps (n=549) women who reported feeling more empowered than other women increased from 32% (based on recall) to 82% after the program (p<.001). Sullivan et al Thai-Burma Program to improve quality of RH Pre- and post-intervention facility Improved program readiness Low (2004) [43] border services and build health providers’ audits, observations of client- contributed to improved quality of capacity in monitoring and provider interactions during ANC information given to clients, evaluation and FP visits, client exit interviews technical competence and (2001-2003) integration of services, although some contradictory findings from client exit interviews warrant further exploration. 1,2,3,4,5These articles refer to the same program.

35 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

RESEARCH Open Access Tracking humanitarian funding for reproductive health: a systematic analysis of health and protection proposals from 2002-2013

Abstract Background: The Inter-agency Working Group on Reproductive Health in Crises conducted a ten-year global evaluation of reproductive health in humanitarian settings. This paper examines proposals for reproductive health activities under humanitarian health and protection funding mechanisms for 2002-2013, and the level at which these reproductive health proposals were funded. Methods: The study used English and French health and protection proposal data for 2002-2013, extracted from the Financial Tracking Service (FTS) database managed by the United Nations Office for the Coordination of Humanitarian Affairs. Every project was reviewed for relevance against pre-determined reproductive health definitions for 2002-2008. An in-depth analysis was additionally conducted for 2009-2013 through systematically reviewing proposals via a key word search and subsequently classifying them under designated reproductive health categories. Among the relevant reproductive health proposals, counts and proportions were calculated in Excel based on their reproductive health components, primarily by year. Contributions, requests, and unfunded requests were calculated based on the data provided by FTS. Results: Among the 11,347 health and protection proposals issued from 345 emergencies between 2002 and 2013, 3,912 were relevant to reproductive health (34.5%). The number of proposals containing reproductive health activities increased by an average of 21.9% per year, while the proportion of health and protection sector appeals containing reproductive health activities increased by an average of 10.1% per year. The total funding request over the 12 years amounted to $4.720 billion USD, of which $2.031 billion USD was received. Among reproductive health components for 2009-2013 proposals, maternal newborn health comprised the largest proportion (56.4%), followed by reproductive health-related gender-based violence (45.9%), HIV/sexually transmitted infections (37.5%), general reproductive health (26.2%), and lastly, family planning (14.9%). Conclusion: Findings show that more agencies are responding to humanitarian appeals by proposing to implement reproductive health programs and receiving increased aid over the twelve year period. While such developments are welcome, project descriptions show comparatively limited attention and programming for familyplanning and abortion care in particular.

Correspondence: [email protected] 1Women’s Refugee Commission, 122 East 42 Street, New York, New York 10168, USA Full list of author information is available at the end of the article

© 2015 Tanabe et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/ licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available 36 in this article, unless otherwise stated. Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

Background Movement, bilateral aid, in-kind assistance, Access to reproductive health services is a and private donations to crises where appeals human right [1]. Yet, lack of access to have been launched. Appeals are primarily reproductive health information and services launched when needs exceed the ability of continues to cause excess morbidity and the government and any one agency to mortality for displaced women and girls in respond adequately to a conflict, natural humanitarian settings [2]. The causes of poor disaster, or prolonged crisis [6]. The FTS reproductive health for conflict-affected primarily focuses on flash and consolidated populations are complex and multifold, appeals [7]: the Flash Appeal is a tool for including insufficient attention that certain structuring a coordinated humanitarian components of reproductive health continue response to address urgent life-saving needs to receive despite concerted advocacy [3]. A in the first three to six months of an 2009 study published by Patel et al. found emergency. If the emergency continues that among total official development beyond six months, the Flash Appeal may be assistance (ODA) disbursed to 18 conflict- developed into a Consolidated Appeal (CAP) affected countries in 2003-2006, only 2.4% of up to 12 months. The CAP includes the was allocated to reproductive health-related Common Humanitarian Action Plan activities and services, of which a mere 1.7% (CHAP), which is a strategic plan for was dedicated towards family planning humanitarian response in a specific country activities [4]. Another study by Hsu et al. in or region [8]. During appeal development, 2013 found a slight increase in aid for cluster/sector coordinators are responsible reproductive health for 2009-2010 and a for gathering project proposals. They lead steady contribution overall; yet, due to the peer review process of vetting proposals; discrepancies in funding across reproductive issued and listed appeals therefore only health activities, the authors note the need to include approved proposals, although examine resource allocations across activities agencies can modify projects as needs evolve and to encourage donors to target aid to [7]. FTS data are provided by donors those most in need [5]. and recipient organizations and include 1-2 One complementary way of tracking page project summaries that are publicly reproductive health assistance in available [9]. humanitarian settings is through reviewing In 2012, the Women’s Refugee project and funding data that are reported to Commission (WRC) used FTS data to the United Nations Office for the examine the extent to which appealed health Coordination of Humanitarian Affairs’ (UN projects included reproductive health OCHA) Financial Tracking Service (FTS); a services for adolescents aged 10-19 years. database that contains up-to-date project and Findings showed that less than 3.5% of all donor information. The FTS is a global, health proposals in any given year included a realtime database that records all reported component of adolescent reproductive international humanitarian aid from UN health, and among them, only 32% received agencies, non-governmental organizations any related funding [10]. Such methods of (NGOs), the Red Cross/Red Crescent analysis are invaluable to tracking progress 37 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

and measuring the impact of reproductive found only one article in the literature that health-related advocacy. systematically analyzed FTS data for mental As part of the Inter-agency Working health and psychosocial support initiatives Group (IAWG) on Reproductive Health in [15]. In the gray literature, CARE Crises’ ten-year global evaluation of International has conducted a review of FTS reproductive health in humanitarian settings, appeals from 17 countries to examine donor the WRC embarked on an analysis to spending on gender in emergencies as examine for 2002-2013: 1) the extent to indicated by scores from the gender marker which humanitarian and development [16]. Our study therefore aimed to contribute agencies, as well as local actors, have to the literature on programming and proposed to implement various reproductive funding for reproductive health in health activities in humanitarian health and humanitarian settings, through conducting a protection appeals; and 2) the level at which comprehensive and systematic analysis of these reproductive health proposals were health and protection proposals for the years funded. This study complements a follow-up 2002-2013. study undertaken by Patel et al. that examines longer-term trends in patterns of ODA for Methods reproductive health activities in conflict- Data source affected countries for the years 2002-2011 All data used in this study were extracted [11]. The FTS study was undertaken since from OCHA’s FTS (http://fts.unocha.org/). ODA analysis of funding towards gender- More specifically, in August 2013, the WRC based violence (GBV) programs is not extracted health and protection project data possible due to a lack of a purpose code in from every conflict, natural disaster, or the Creditor Reporting System (CRS) to protracted crisis where a Flash, CAP, or other which ODA is mandatorily reported by appeal was launched between 2002 and 2012 bilateral donors under pre-set aid categories. from FTS’ country-specific excel In addition, while the CRS provides conflict- spreadsheets: “E. List of Appeal Projects affected countries as the unit of analysis, the (grouped by Cluster) with funding status of FTS presents the ability to determine each” (Spreadsheet E). This was further projects and funds that are directly availed to supplemented by custom tables that could be specific emergencies within countries, albeit created through following the FTS’s reported by implementing agencies and “Funding and Requirements by Project” tool donors in a voluntary manner [12]. This where necessary [17]. Appeals from 2013 enables a closer examination of projects and were extracted in March 2014. Appealed funding that directly targets emergencies, projects included those published in both overcoming assumptions that all ODA to a English and French; the two languages for conflict-affected country in fact reaches the which appeals are available. conflictaffected location. Despite several The data points from all emergencies articles that employed CRS data to track over the 12 year period were compiled into a funding flows to health and other relevant master Excel file where only appeals from humanitarian topics [13,14], the authors Health and Protection were kept for 38 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

analysis.a In addition to Spreadsheet E, for words were only mentioned in the 2009-2013, the study team downloaded all background or needs sections, the proposals hyperlinked pdf “Project Descriptions” were omitted from the tallies since they were (project proposals) accessible from considered less likely to actually implement Spreadsheet E’s “Project Code” column. relevant activities than those that contained Since not all project descriptions were key words as part of their activities or publicly available from years prior to 2009, indicators. the study retrieved OCHA’s accompanying For each relevant proposal, the analysis comprehensive narrative appeals for 2005- team categorized activities according to pre- 2008 in lieu of the project proposals. For determined definitions of reproductive 2002-2003, only Spreadsheet E was extracted health components. The definitions modeled given the lack of availability of project distinctions made between the Minimum descriptions and narratives. Spreadsheet E Initial Service Packagec (MISP) for was thus the common data source for all 12 reproductive health—the international years. minimum standard of care for reproductive health in emergencies—and more Analysis comprehensive reproductive health per the Two WRC staff (KS and SR) analyzed the Inter-agency Field Manual on Reproductive Health health and protection proposals; one of in Humanitarian Settings (IAFM) [18]. whom analyzed those from 2009 to 2010; the Activities were further categorized into other the remaining ten years. They thematic components; namely: maternal conducted in-depth analysis of health and newborn health; family planning; sexually protection proposals for 2009-2013 since all transmitted infections (STIs), including HIV; pdf proposals were available. The team gender-based violence (GBV); and general assessed the content of each proposal by reproductive health. GBV findings were clicking the hyperlinked pdf “Project additionally categorized as reproductive Descriptions” and conducting systematic key health-related activities and non-reproductive word searches within the activities and health-related activities. Reproductive health- indicators sections of each proposal.b Terms related GBV activities included clinical used included “repro,” “MISP,“ maternal,” interventions, as well as those outlined in the “preg,” “family planning,” “condom,” “sex” IAFM to be within the scope of (for sexual violence, etc.), “gender” (for reproductive health. Non-reproductive gender-based violence, etc.), “STIs” (for health-related GBV activities included legal sexually transmitted infections), “adolesc” justice, protection, security, livelihoods, and (for adolescents/adolescence),“youth,” gender, among other complementary among others. Where seemingly relevant interventions. A detailed categorization proposals were identified, the team read the of reproductive health activities is listed in proposals to ensure that key words were Table 1. nuanced appropriately and related activities As each proposal was 1-2 pages, some were not missed if other terms were used to discretion was made on the part of the address possible political sensitivities. If key analysis team on how to categorize activities. 39 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

In general, if the “MISP” was mentioned, it Among the relevant reproductive health was assumed for categorization purposes proposals, counts and proportions were that agencies implemented the standard in its calculated in Excel based on their manual entirety. While in reality, many reproductive categorizations, primarily by year. health activities overlap in terms of their Contributions, requests, and unfunded thematic categories—such as the prevention requests were calculated based on the data of mother-to-child transmission of HIV provided in Spreadsheet E. The total request (PMTCT) as part of HIV and maternal per year was determined by summing newborn health services—to prevent spreadsheet E’s “Revised requirements inflated and duplicative counts, activities USD” column. The total request funded was were categorized mutually exclusively into found by summing “Funding USD,” and the the five thematic reproductive health total unfunded request was calculated by components per the MISP and summing “Unmet requirements USD”. For comprehensive reproductive health (minus 2009-2013, funds from these columns were the MISP). A pictorial representation of the further divided by the number of five reproductive health categories is noted reproductive health components that were in Figure 1. encompassed in each proposal and then For 2002-2008 appeals, given limited summed to calculate total request, total availability of publicly accessible information request funded, and total unfunded request on FTS, a more cursory analysis was per reproductive health component. conducted to determine the projects’ Among the projects analyzed, duplicate relevance to reproductive health. Projects proposals in the context of revised appeals funded from 2005 to 2008 were deemed were included to take into account program relevant if their titles or accompanying evolution over time. Duplicate proposals comprehensive narrative reports—generated arising from multiple agency requests for the by OCHA on behalf of the humanitarian same project were also included given the system—mentioned reproductive health impossibility of delinking projects without components or related activities. For 2002- additional information and verification 2005, due to the additional lack of accessible processes with appealing agencies. comprehensive narratives, projects were Withdrawn or blank proposals were coded as relevant if titles—which were the additionally included for analyses; however, only specific column available on this had no impact on funding calculations Spreadsheet E—mentioned reproductive since those columns from FTS were blank. health components or related activities. In order to complement Patel et al.’s Taking into account the documented relative ODA analysis, this study similarly grouped lack of attention to reproductive health in proposals according to the 18 conflict- the earlier years as compared to later years affected countries and all other countries [2], the study team included the earlier years where appeals were launched. The 18 despite some possibility of under- countries included Afghanistan, Angola, identification of relevant projects where only Burundi, Central African Republic, Chad, Spreadsheet E was available. Colombia, Democratic Republic of Congo, 40 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

Table 1 Categorization of reproductive health activities per the IAFM [18] gp p Topic MISP Comprehensive reproductive health Non- (excluding MISP activities) reproductive health Maternal • Emergency obstetric and newborn care services, including post- • Antenatal care (ANC). • Nutrition newborn abortion and safe abortion care. • Post-natal care. outside of ANC. health • 24/7 referral system for obstetric and newborn emergencies. • Breastfeeding promotion. • Clean delivery packages to visibly pregnant women and birth • Training skilled attendants (midwives, nurses, attendants. doctors) in performing EmOC and newborn • Informing communities about services. care. Family • Contraceptives to meet demand, such as condoms, pills, • Comprehensive family planning N/A planning injectables, and intrauterine devices. programming, including provision of long- term and permanent methods. • Community education. • Contraceptive supply chain management. • Staff training for family planning. STIs/HIV • Safe and rational blood transfusion practice. • Comprehensive STI prevention and N/A • Adherence to standard precautions. treatment. • Free condoms. • STI surveillance systems. • Syndromic treatment for STIs. • Comprehensive HIV prevention, care, and • Antiretroviral (ARV) treatment for patients already taking ARVs. treatment. • Prevention of mother-to-child transmission. • Staff training for HIV/AIDS. GBV • Sexual violence coordination within health sector/cluster • Prevention of domestic violence, forced • Multi-sectoral mechanisms. early marriage, female genital cutting/ GBV • Physical protection and strategies for safe access to health mutilation. coordination. facilities, including lighting and locks on latrines; prevention of • Engaging men and boys, primarily to • Legal justice sexual exploitation and abuse; codes of conduct; standard enhance access to RH for women and girls. • Protection operating procedures. • Staff training for clinical GBV. • Child protection • Clinical care for survivors of sexual violence, including • Livelihoods emergency contraception, post-exposure prophylaxis, etc. Forensic • Security evidence is also included if applicable. • Education • Other response services including psychosocial and mental • Empowerment health services. • Gender • Referrals to sexual violence services. • Trafficking • Informing communities about services. • Unspecified “protection” activities • GBV Information Management System General • RH coordination, including identifying an RH officer; holding • General staff trainings for unspecified topics. N/A reproductive coordination meetings; reporting back to the health cluster/sector. • Routine RH procurement for unspecified health • Procurement of RH kits and supplies. topics. • Planning for comprehensive RH, including collecting MISP and • Routine data collection beyond MISP background data; identifying sites for future delivery of indicators. comprehensive RH; assessing staff capacity and planning trainings; • Cervical cancer screening and treatment. and procuring RH supplies. • Fistula repair. • Disaster risk reduction. • Treatment of female genital mutilation/ • Menstrual hygiene; dignity kits. cutting complications. • Other gynecological services. • Unspecified RH activities.

Eritrea, Iraq, Liberia, Myanmar, Nepal, Sierra funds could not be extracted, these appeals Leone, Somalia, Sri Lanka, Sudan, Timor- were excluded from the 18 country count. Leste, and Uganda. As Patel et’ al.’s study included South Sudan as part of the “Sudan” Results category, this study also added South Sudan Findings to the list of 18 original countries from 2011 when distinctions between Sudan and South Overall findings for 2002-2013 Sudan were made in the FTS. Where regional In total, 11,347 health and protection appeals were launched—West Africa in proposals from 345 emergencies were issued particular—as country-specific activities and between 2002 and 2013. The major 41 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

the lowest number of relevant reproductive health projects, with 87 identified for Health and 15 for Protection. On the other hand, while a drop was observed in 2012, the general trend showed progressive increases, with 2013 marking the highest number of relevant reproductive health proposals (570). In 2013, 380 health and 190 protection

FigureFi 1 1 proposals were identified as relevant to reproductive health (53.4% of total health humanitarian emergencies during this time and protection proposals). See Figures 2 and included: crises in the Southern African 3 for details . region (2002-2003), Indian Ocean Funding requests from the relevant earthquake and tsunami (2005), earthquake reproductive health projects over the 12 years in Haiti (2010), floods in Pakistan (2011), the amounted to $4.720 billion USD. From this, Syria conflict (2012-2013), and food $2.031 billion USD was received, with an insecurity in Sub-Saharan Africa throughout unfunded request of $2.689 billion USD the decade. Among the 11,347 proposals, the (57.0%). Hence, 43.0% of the total request study identified 3,912 proposals that were was funded, with an average of 39.6% of the relevant to reproductive health, which request funded per year. Reproductive health amounted to 34.5% of all health and projects were least funded in 2006 (19.5%), protection proposals combined. and most funded in 2008 (56.5%). The From 2002 to 2013, there was a 136.4% overall change in funding requests from 2002 increase in the number of proposals to 2013 was 771.5%, with a 17.9% average requesting funding under Health and a annual increase in the proportion of requests 200.8% increase in the number of proposals received per year. Absolute amounts further requesting funding under Protection. This showed that funding towards reproductive amounted to an average annual increase of health projects increased from approximately 9.8% and 13.3%, respectively. By contrast, $38.3 million in 2002 to $498.3 million in during the two time intervals, the number of health and protection proposals that addressed some component of reproductive health increased by 336.8% and 1,166.7%, respectively. This reflected a combined average annual increase of 21.9%, or 17.9% for Health and 43.6% for Protection over the 12 year period. In terms of proportions, reproductive health accounted for 34.5% of health and protection sector proposals, with an average annual increase of 10.1% per year. In terms of absolute counts, 2002 marked Figure 2 42 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

2013, which was 35.0% and 52.3% of the funding request in 2002 and 2013, respectively. See Figure 4 for more information.

In-depth analysis for 2009-2013 For the five year period from 2009 to 2013, a total of 5,636 proposals were filed for the two sectors, which comprised 3,358 health and 2,278 protection proposals. Among these, 2,477 were relevant to reproductive Figure 3 health (43.9%). From 2009 to 2013, a decrease in the number of issued health and to 59.1% in 2013. Family planning and protection proposals was observed by 15.5% general reproductive health activities showed and 34.4%, respectively. This translated to an a similar trend, at 9.8% and 23.7%, average annual decrease of 2.8% and 9.3% respectively in 2009. They both peaked at for health and protection proposals, 27.9% and 39.8% in 2012, before decreasing respectively. On the contrary, the share of to 11.1% and 17.4% in 2013, respectively. relevant reproductive health proposals The proportion of proposals addressing increased for both sectors, with overall and HIV/STIs steadily decreased over the five average annual increases of 19.9% and 7.4%, year period, from 45.7% in 2009 to 26.7% in and 25.8% and 18.5%, for Health and 2013. This marked an average annual Protection, respectively. Indeed, the decrease of 12.4% in proportions. The share proportion of reproductive health proposals of proposals that included reproductive among both health and protection proposals health components as relevant to GBV grew increased from 33.6% in 2009 to 53.4% in marginally (average annual increase of 2.7%), 2013, which translates to a 15.3% average with proportions ranging between 41.9% and increase in the number of relevant 48.7% in 2009 and 2011 before decreasing to reproductive health proposals per year. Table 2 notes this information. A closer examination of the types of reproductive health projects appealed during the five year period showed that activities within maternal newborn health comprised the largest proportion (56.4%), followed by GBV (45.9%), HIV/STIs (37.5%), general reproductive health (26.2%) and lastly, family planning (14.9%). As shown in Figure 5, the proportion of reproductive health proposals addressing maternal newborn health was 49.1% in 2009, 64.1% in 2012 and dropping Figure 4 43 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

44.5% and 46.1% in 2012 and 2013. For GBV specifically, findings showed While a substantial number of proposals that 73.8% (1,136) of all GBV-related health appealed to implement more than one and protection proposals (1,540) were component of reproductive health, when relevant to reproductive health as defined by funding trends for the five reproductive the IAFM. Non-reproductive health-related health components were analyzed for the five GBV proposals were those that solely year period, findings showed that maternal appealed to implement non-health-related or newborn health (55.7%) received the most broader GBV interventions (see Table 1). funds as a proportion of requested funds, Proposals containing reproductive followed by general reproductive health healthrelated GBV among all GBV (47.4%), family planning (47.4%), HIV/STIs proposals ranged from 64.5% (2010) to (38.5%), and GBV (37.0%). In terms of 89.2% (2013), with an average annual absolute amounts, this translated to maternal increase in share of 9.0%. newborn health receiving $684.8 million USD, general reproductive health $180.0 Trends from 18 conflict-affected million USD, family planning a mere $76.3 countries million USD, HIV/STIs $227.6 million USD, In total, 3,988 health and 2,218 protection and GBV $308.9 million USD. Hence, family proposals were issued to aid the 18 conflict- planning received the least dollar amount affected countries between 2002 and 2013. among the reproductive health components. This amounted to 54.7% of all issued sector See Figure 6 for trends. proposals within the 12 year period. Among In terms of objectives and priority the 6,206 total proposals, 2,303 (37.1%) activities that comprise the MISP standard, contained reproductive health activities. This the proportion of reproductive health marked an overall 400.0% increase from proposals that noted complete MISP 2002 to 2013, with an average annual implementation (via explicit mention or a increase of 21.1%. In 2002, the proportion compilation of activities) increased from of health and protection proposals 3.0% in 2009 to 5.4% in 2010. This containing reproductive health activities was proportion jumped to 11.9% in 2012 before 22.5%, and in 2013, this was 59.5%. decreasing to 4.7% in 2013. Proposals that Within the 2009-2013 five year period contained MISP activities in their partial where in-depth analysis was conducted, form followed similar trends over the five maternal newborn health activities year period, starting at 46.6% in 2009, comprised the majority of reproductive jumping to 53.3% and 69.1% in 2011 and health proposals (59.4%), which increased 2012, respectively, before decreasing to from 47.3% of reproductive health 44.6% in 2013. Figure 7 shows these trends. proposals in 2002 to 65.1% in 2013. Overall, full MISP and partial MISP HIV/STI activities (40.2%) were second proposals comprised 5.6% and 50.3% of most mentioned, followed by reproductive reproductive health proposals, respectively, health-related GBV (38.8%) and general with an average increase of 39.5% and 2.4% reproductive health (23.0%), with family per year across the five years. planning mentioned least (12.3%). Similar to 44 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

Table 2 Relevant reproductive health proposals, 2009-2013 ppp Annual Overall Average Total 2009 2010 2011 2012 2013 Average change change Number of health proposals 672 -15.5% -2.8% 3,358 814 712 600 544 688 Number of protection proposals 456 -34.4% -9.3% 2,278 578 551 406 364 379 Number of relevant RH proposals 495 21.8% 10.0% 2,477 468 533 544 362 570 RH proposals (Health) 335 19.9% 7.4% 1,673 317 353 356 267 380 RH proposals (Protection) 161 25.8% 18.5% 804 151 180 188 95 190 Proportion of RH proposals among total sector proposals 44.6% 58.9% 15.3% 43.9% 33.6% 42.2% 54.1% 39.9% 53.4% Proposals with full MISP implementation 28 92.9% 31.2% 139 14 29 26 43 27 Proposals with partial MISP implementation 249 16.5% 4.8% 1246 218 234 290 250 254 Proportion of full MISP proposals among total relevant RH 6.0% 58.3% 39.5% 5.6% 3.0% 5.4% 4.8% 11.9% 4.7% proposals Proportion of partial MISP proposals among total relevant 51.5% -4.3% 2.4% 50.3% 46.6% 43.9% 53.3% 69.1% 44.6% RH proposals RH proposals addressing MNH 279 46.5% 13.2% 1,397 230 292 306 232 337 RH proposals addressing FP 74 37.0% 18.0% 370 46 86 74 101 63 RH proposals addressing HIV/STIs 186 -29.0% -3.0% 930 214 240 211 113 152 RH proposals addressing RH-related GBV 227 34.2% 14.4% 1,136 196 251 265 161 263 RH proposals addressing general RH 130 -10.8% 0.0% 648 111 150 144 144 99 Proposals solely addressing non-RH GBV 81 -67.0% -13.9% 404 97 138 65 72 32 Proposals addressing any type of GBV 308 0.7% 3.7% 1,540 293 389 330 233 295 Proportion of MNH proposals among total relevant RH 56.7% 20.3% 5.1% 56.4% 49.1% 54.8% 56.3% 64.1% 59.1% proposals Proportion of FP proposals among total relevant RH 15.7% 12.4% 23.3% 14.9% 9.8% 16.1% 13.6% 27.9% 11.1% proposals Proportion of STI/HIV proposals among total relevant RH 37.5% -41.7% -12.4% 37.5% 45.7% 45.0% 38.8% 31.2% 26.7% proposals Proportion of RH-related GBV proposals among total 45.7% 10.2% 2.7% 45.9% 41.9% 47.1% 48.7% 44.5% 46.1% relevant RH proposals Proportion of general RH proposals among total relevant 27.1% -26.8% 1.7% 26.2% 23.7% 28.1% 26.5% 39.8% 17.4% RH proposals Proportion of GBV-RH relevant proposals among total GBV 74.0% 33.3% 9.0% 73.8% 66.9% 64.5% 80.3% 69.1% 89.2% proposals

the overall trends, all components were million USD (51.9%). Similar overall increasingly mentioned other than proportions were observed across the 2002- HIV/STIs, which dropped by an average of 2011 years of Patel et al.’s study: the total 9.2% per year. See Figure 8 for more funding request was $1.933 billion USD, with information. $775.0 million USD received. This In terms of funding, the total request for comprised 40.1% of the total request, reproductive health-related projects in the 18 leaving a total unfunded request of $1.158 conflict-affected countries was $2.777 billion billion USD [11]. Figure 9 contains additional USD for the 12 year period. The amount information. received was $1.165 billion; roughly 41.9% of the total request. The combined unfunded Discussion request was $1.612 billion USD. In 2002, the Overall trends request to funding received was $77.3 million Findings show increases in the number of USD to $30.7 million USD (39.7%), while in proposals issued, proportion of proposals 2013, this was $512.4 million USD to $265.8 addressing reproductive health, and the 45 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

appeals processes and are including reproductive health activities in their proposed programs. Such progress reflects the increasing participation of non- traditional actors in interagency funding mechanisms; awareness around the integration of reproductive health into global standards and guidance—such as the 2010 Sphere Standards, the 2009 Inter-agency Standing Committee Health Cluster Guide,

Figure 5 and numerous other global policies and guidelines—as well as concerted advocacy amount of requested and received funds for that was undertaken by IAWG members over reproductive health during the 12 year period the last decade to ensure MISP examined: 2002-2013. An average annual implementation at the onset of an increase of 21.9% in absolute numbers of emergency in particular [3,18-22]. proposals that include reproductive health The total funding request over the 12 and an average annual increase of 10.1% in years amounted to $4.720 billion USD, of the proportion of health and protection which $2.031 billion USD was received. proposals that include reproductive health While only 43.0% of the request was met, marks great strides in recognition of trends still show a 17.9% average annual reproductive health needs in emergencies. increase in the proportion of requests When the type of appealing agencies are received per year. Further, as a broader examined, they include the UN Population comparison over the 12 year period, total Fund and large humanitarian organizations, health sector proposals averaged 40.7% in as well as local NGOs, Ministries of Health, funds received per total CAP requests and and non-traditional reproductive health total protection sector proposals averaged actors that are increasingly participating in 36.5%. Despite the data limited to the CAP,

Figure 6

46 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

Figure 7 Figure 8

this shows that reproductive health in fact components, it is important to emphasize the faired above Health and Protection averages, small number of proposals that in fact and was funded at only a slightly lower included family planning activities. Moreover, proportion than Water and Sanitation most proposals embedded family planning (averaging 44.1%). Overall, total sector with other maternal newborn health or HIV proposals averaged 67.7% funding, with prevention activities, possibly leading to an Health and Protection ranking fifth and over-estimation of projects that substantially tenth out of the eleven sectors (excluding addressed family planning needs. Indeed, “Sector Not Yet Specified”), respectively. among the reproductive health components, Highest funded sectors were Food (averaging proposals were least specific about the types 85.7%), Coordination and Support Services of family planning services offered, and (averaging 71.9%), and Multi-sector long-acting and permanent methods were (averaging 68.9%) [23]. seldom mentioned. All of these observations reflect the limited attention towards family In-depth analysis for 2009-2013 planning in humanitarian settings, although The proportion of reproductive health possible caveats exist and are explained in proposals appealing to implement maternal further depth below. newborn health, family planning, and general Further, studies have shown that HIV reproductive health for 2009-2013 mirrors has received substantial implementation and other IAWG global evaluation findings [22]. donor attention relative to other reproductive This shows increasing awareness towards the health components [4]. It is important to need to address reproductive health in note that proposals with HIV/STI humanitarian settings. However, when components tended to emphasize PMTCT examining funds received, maternal newborn as their primary focus versus comprehensive health received the most funding at $684.8 treatment and prevention activities. The five million USD, while family planning received year analysis shows that proposals addressing the least, at $76.3 million USD. While family HIV/STIs steadily decreased over the five planning received comparable proportions year period, from 45.7% in 2009 to 26.7% in of funding per request as compared to 2013. The proportion of received funds several other reproductive health (38.5%) and absolute amounts ($227.6

47 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

AIDS, Tuberculosis and Malaria (Global Fund) in fragile states, which may have contributed to HIV being considered a lower priority in humanitarian response [24,25]. Further, despite due emphasis on the continued need to ensure access to HIV prevention, care, and treatment, recognition that conflict and forced displacement does not necessarily lead to increased HIV Figure 8 prevalence may have also had its effects [26]. Indeed, the steady decline in the million USD) were similarly less than those proportion of proposals containing received for proposals that included maternal HIV/STI activities (12.4% average decrease) newborn health activities (55.7% and $684.8 was met with an increase in the absolute billion USD). When examining reproductive number of proposals containing health components via information available reproductive health-related GBV activities in Spreadsheet E for earlier years however, (14.4% average increase). Increased attention other observations are noteworthy. Health to reproductive health-related GBV and protection proposals with HIV-related programming is also reflected in the larger activities in fact comprised the largest share requested and received amounts of funding of reproductive health components from for 2010-2013 where such funds exceeded 2002-2008; only in 2009 did maternal those for HIV/STIs, family planning, and newborn health proposals outrank HIV/STI general reproductive health (aside from proposals. In terms of funds received, 2012) activities. The increase in proposals HIV/STI proposals were most funded in containing GBV could be the result of 2003; however, the frequency with which strong emphasis and collective advocacy to antenatal and post-natal care was mentioned flag GBV as a salient and prevalent issue in is the likely reason behind skewed funding to crises, especially through UN Security the maternal newborn health component. Council Resolutions on Women, Peace and While prior year information was not Security; the UN Secretary-General’s included as part of the in-depth analysis “UNiTE to End Violence against Women” given probable under-identification of campaign; and the work of the GBV Area of proposed reproductive health activities Responsibility, Gender Standby Capacity where they were not noted in Spreadsheet E, Project advisors, and other initiatives such as the steady decline of HIV/STI proposals the gender marker [27-30]. over 2009-2013 may thus be a result of In 2012, a major dip was observed in the changing need, integrated programming, or proportion of sector proposals that included an equilibration of funding towards other reproductive health. Absolute numbers of reproductive health components. Alternative health and protection proposals decreased in explanations may be a result of expanded 2012, as did the share of reproductive health, programming by the Global Fund to Fight with a 33.5% reduction in the number of 48 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

relevant sector proposals identified from the although mentioned (as noted above); for previous year. Among the relevant HIV/STIs, PMTCT and safe transfusions reproductive health proposals however, the were commonly mentioned in proposals share of maternal newborn health, family where HIV activities were included. Clinical planning, and general reproductive health care for survivors of sexual violence and increased by 13.9%, 105.1%, and 50.3%, psychosocial care were most often respectively. Further, 2012 showed the mentioned for the reproductive health- highest proportion of proposals noting full related GBV component. Hygiene kits that or partial MISP implementation (11.9% and encompassed menstrual hygiene were often 69.1%, respectively). Hence, the decrease in listed for the general reproductive health the absolute numbers of relevant proposals component. The frequency that antenatal may possibly be explained by the fact that and post-natal care—neither a part of the individual proposals addressed multiple MISP—were mentioned further contributed reproductive health components or pledged to the large share of maternal newborn to deliver a wider set of services. While the health proposals overall, despite EmOC true reason is unknown, an important point being more effective at reducing maternal to note is the value of examining the morbidity and mortality [18]. In addition, proportion of sector proposals with nutrition was frequently mentioned in both reproductive health components and the health and protection proposals in 2013; proportion of specific reproductive health specifically, the intersections between components within relevant reproductive maternal newborn health and nutrition that health proposals, rather than the mere skewed proposals and funded amounts for absolute count that does not reflect the this component. breadth and depth of programming. The lack of specification of family Indeed, among relevant proposals, some planning services and mention of abortion- activities were more often mentioned than related services may have been a result of others, even as proposals became agencies’ concerns over political and donor increasingly detailed over the years. This sensitivities, or legal restrictions in the case presumably shows growing recognition and of the latter. Similarly, seemingly benign understanding of what a reproductive health umbrella terms such as “maternal health” or response entails in emergencies, including even “emergency obstetric care” may have appreciation of the MISP standard [22]. For been used to denote more sensitive and MISP activities, among maternal newborn specific services, or certain populations such health services, emergency obstetric care as adolescents omitted, so that such services (EmOC) and clean delivery kits were could be provided discreetly. The inability to frequently mentioned. Despite reference to accurately comprehend the services that are EmOC, abortion care of any kind was rarely in fact provided at the field level is a major mentioned; where it was mentioned in 13 limitation of a key word search-based proposals (two were withdrawn) was in the method. However, while projects for the context of post-abortion care. Family Middle East North Africa region for planning as a component was least described instance, often did not mention reproductive 49 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

health and GBV activities per se, a closer classification differences in what constituted read of the project descriptions and names reproductive health activities. Key of the appealing agency could often shed differences between the 18 countries and the light on the project scope, and where such overall trend are the proportions of specific information could be garnered, the proposals reproductive health components within were marked under the relevant five relevant proposals for 2009-2013: HIV/STIs reproductive health components. A further proposals held a higher share among noteworthy observation is that while Marie proposals appealed for the 18 countries, Stopes International is a critical provider of ranking second overall. Family planning abortion-related care and is increasingly however, mirrored overall trends and was responding in emergencies, the agency was mentioned in a mere 12.3% of relevant only listed for seven projects over the 12 year reproductive health proposals. period, reflecting a likely under-estimation of such service provision. While traditionally Limitations “development” actors are progressively Several limitations exist in this study. First, responding in emergencies, there appears to the analysis is solely based on desk research remain a time lag in their participation in the of proposals submitted through the FTS. FTS process, especially. Hence, the limited Hence, the analysis is only as accurate in-so- references to family planning and abortion- far as agencies voluntarily report their related services likely reflects a multitude of planned activities. Some of the Gulf States factors, although other IAWG global and Islamic charities are yet to actively evaluation studies have indeed documented participate in the FTS, which misses their the disproportionate lack of availability of relevant efforts [32]. Some reproductive long-term and permanent methods of family healthrelated activities may have also been planning and abortion services in particular missed due to human error; if activities were [31]. not mentioned in the proposal or were In terms of cross-cutting populations, subsumed under vague descriptions due to adolescents and persons with disabilities political sensitivities; or if modifications were were mentioned across years, but in very few made beyond what was captured in appeals proposals. These proposals were typically revision processes. This study looked at entirely dedicated to the specific population, projected programming and funding for showing limited mainstreaming. Trends from reproductive health as addressed in health 18 conflict-affected countries Patel’s study and protection proposals submitted to the found that the average annual ODA FTS. Thus, findings indicate practitioner and disbursed for reproductive health to 18 donor recognition of the need for conflict-affected countries from 2002 to reproductive health in emergencies and 2011 was $747.0 million USD. While this cannot speak to actual implementation or the study calculated the total amount at $775 quality of services provided. Limitations of million USD for the same time period, the the desk research further apply to the discrepancies are explainable from the amount of received funds; if contributions different units of analyses, as well as several were not reported through the FTS, the 50 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

information was not captured in this study. Fifth, to prevent inflated and duplicative Second, duplicate appeals are included in counts within reproductive health thematic the context of revised appeals to account for areas, activities were categorized into five evolving programming with time. Duplicate thematic areas per the MISP and programs have also been included where an comprehensive reproductive health (minus umbrella organization—typically a UN the MISP) for the 2009-2013 in-depth agency—has appealed for the same project analysis. The counts for each thematic area that is in fact implemented by international are therefore likely to be under-represented. and national partners. Their inclusion, Sixth, as only health and protection however, brings about discrepancies in funds proposals were analyzed, any relevant received. While appeals include multiple activities appealed in other sectors/clusters agency requests for the same project— would have been missed. These include especially where partnership arrangements large-scale infrastructural improvements that have been made—when funds are received, could support EmOC transfers, menstrual they are most likely reflected as received by hygiene as included under non-food item the umbrella agency, and not by all of its sub- distributions, related projects under Water grantees [33]. The unfunded request will thus and Sanitation, or multi-sectoral projects that be systematically overestimated across years. were not mentioned in Health/Protection. Third, and related to duplicate counts, However, protection proposals were since it was not possible to untangle the analyzed to minimize underrepresentation of amount of money that was distributed across GBV-related projects. different reproductive health components Seventh, given challenges to linking where proposals appealed to implement donor contributions to exact appeals through multiple components, the study assumed that the FTS, only aggregate funding was agencies proportionally allocated requested examined. This limits comparisons with the and received funds across the number of ODA analysis where the type of donor was mentioned reproductive health components examined in-depth. for the 2009-2013 analysis. This may contribute some inaccuracies if proposals Conclusions focused on certain components over others This study is the first in-depth analysis that that they addressed; however, the authors reviewed commitments to reproductive deemed that this would be more accurate health through project and funding data than not weighting the proposals at all. reported to the FTS. Findings show that Fourth, while originally, all proposals more agencies are appealing to implement across 2002-2008 were planned for an in- reproductive health programs in terms of the depth review, full narrative appeals were only number of issued proposals and funding available from 2005, and all project requested over the 12 year period. The descriptions (proposals) from 2009. Hence, absolute amounts received by agencies to to conduct a consecutive 5-year analysis, the implement relevant reproductive health study team added data from 2013 for analysis activities also increased during this time. of 2009-2013. While such developments are welcome, 51 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

based on project descriptions and the who conducted a pilot analysis in 2011. The team scope of this analysis, proposals show would also like to express our gratitude to the comparatively limited attention and FTS team at OCHA; namely, Julie Ann Thompson, Miriam Lange and Luciano Natale, who provided programming for family planning services much assistance and insight into the data and to abortion care in particular. At extraction and interpretation process. We would the intersections of the International also like to thank Catrin Schulte-Hillen of Conference on Population and Development Medecins Sans Frontieres and Louise Lee-Jones who were original members of the funding plus 15 and the Post-2015 Agenda, the analysis team, as well as Sarah Frank timing is opportune to scale-up attention and who coordinated the IAWG’s global evaluation access to such critical, life-saving services in of reproductive health in crises. humanitarian response. Declarations This article has been published as part of Conflict and Health Volume 9 Supplement 1, 2015: Taking List of abbreviations used Stock of Reproductive Health in Humanitarian ANC: Antenatal care; ARV: Antiretroviral ; CAP: Settings: 2012-2014 Inter-agency Working Group Consolidated Appeals Process; CHAP: Common on Reproductive Health in Crises’ Global Review. Humanitarian Action Plan; CRS: Creditor The full contents of the supplement are available Reporting System; EmOC: Emergency obstetric online at http://www.conflictandhealth.com/ care; FTS: Financial Tracking Service; GBV: supplements/9/S1. Funding for this supplement Gender-based violence; IAFM: Inter-agency Field was provided by the MacArthur Foundation. Manual on Reproductive Health in Humanitarian Settings; IAWG: Inter-agency Working Group on Authors’ details Reproductive Health in Crises; MISP: Minimum 1Women’s Refugee Commission, 122 East 42 Initial Service Package; OCHA: Office for the Street, New York, New York 10168, USA. 2King’s Coordination of Humanitarian Affairs; ODA: College London, Department of War Studies, Official Development Assistance; PMTCT: King’s College London Strand, London WC2R Prevention of mother-to-child transmission; 2LS, UK. RH: Reproductive Health; STI: Sexually transmitted infection; UN: United Nations; USD: Published: 2 February 2015 United States dollar; WRC: Women’s Refugee Commission. References Competing interests 1. United Nations Population Network: Report of the The authors declare no competing interests. International Conference on Population and Development. Cairo; 1994, A/CONF.171/13: Report Authors’ contributions of the ICPD (94/10/18). MT developed the study methodology, with 2. Austin J, Guy S, Lee-Jones L, McGinn T, Schlecht J: contributions from PP. KS primarily conducted Reproductive health: a right for refugees and the data analysis, with help from SR. MT internally displaced persons. Reproductive Health conceptualized the paper and was principal Matter 2008, 16(31):10-21. author; KS, PP, and SKK contributed to the writing process. All authors reviewed and 3. Reproductive Health Access, Information and Services (RAISE) Initiative: Reproductive Health in approved the final text. Emergencies: A Review of the Policy Environment. New York; 2009. Acknowledgements We greatly acknowledge the work of Dhabie 4. Patel P, Roberts B, Guy S, Lee-Jones L, Conteh L: Brown, who extracted the initial 2002 to 2012 Tracking Official Development Assistance for data set from OCHA’s FTS, as well as Leah Petit, Reproductive Health in Conflict-Affected Countries. 52 Tanabe et al. Conflict and Health 2015, 9(Suppl 1):S2 http://www.conflictandhealth.com/content/9/S1/S2

PLoS Med 2009, 6(6):e1000090. humanitarian settings: linking practice and 5. Hsu J, Berman P, Mills A: Reproductive health research. Lancet 2011, 378:1581-1591. priorities: evidence from a resource tracking analysis 16. CARE International: Donor Spending on Gender in of official development assistance in 2009 and Emergencies 2013: An investigation by CARE 2010. Lancet 2013, 381(9879):1772-82. International UK into the UN data on donor aid to 6. United Nations Office for the Coordination of emergency appeals for 17 countries in crisis. Humanitarian Affairs: Revised Guidelines for Flash London; 2013. Appeals. New York; 2009. 17. Financial Tracking Service: Query Projects from 7. United Nations Office for the Coordination of Financial Tracking Database. [http://fts.unocha.org/ Humanitarian Affairs: Consolidated Appeals pageloader.aspx?page=searchprojectcustomsearch]. Process: About the Process. 2014 18. Inter-agency Working Group on Reproductive [http://www.unocha.org/cap/about-the-cap/about- Health in Crises: Inter-agency Field Manual on process]. Reproductive Health in Humanitarian Settings. 8. United Nations Office for the Coordination of Geneva; 1999, 2010 revision. Humanitarian Affairs: What is the Consolidated 19. The Sphere Project: The Sphere Handbook: Appeals Process? 2014. Humanitarian Charter and Minimum Standards in 9. Financial Tracking Service: About FTS. 2014 Humanitarian Response. Geneva; 2011. [http://fts.unocha.org/pageloader.aspx?page=About 20. Inter-agency Standing Committee: Health Cluster FTS-uctrlAboutFTS]. Guide: A practical guide for country-level 10. Tanabe M, Manohar S, Schlecht J: Adolescent implementation of the Health Cluster. Geneva; Sexual and Reproductive Health Programs in 2009. Humanitarian Settings: An In-depth Look at Family 21. Development Initiatives Ltd: Global Humanitarian Planning Services. New York: Women’s Refugee Assistance Report 2013. Bristol; 2013. Commission, Save the Children, United Nations 22. Tran TN, Dawson A, Meyers J, Krause S, Hickling C: High Commissioner for Refugees, United Nations Developing institutional capacity for reproductive Population Fund; 2012. health in humanitarian settings: a descriptive 11. Patel P, Dahab M, Tanabe M, Ettema L, Guy S, study., Submitted and under review. Roberts B: Tracking Official Development Assistance 23. Financial Tracking Service: Global requirements & for Reproductive Health in Conflict-Affected funding per sector. 2002-2013 Countries: 2002 to 2011., Submitted and under [http://fts.unocha.org/pageloader.aspx?page=emer review. gglobalOverview&Year]. 12. Patel P, Roberts B, Conteh L, Guy S, Lee-Jones L: 24. Global Fund to Fight AIDS Tuberculosis and Malaria: A Review of global mechanisms for tracking official Thematic Review of The Global Fund in Fragile development assistance for health in countries States: Framing Document. 2013 affected by armed conflict. Health Policy 2011, [http://www.theglobalfund.org/documents/terg/eval 100(2-3):116-24. uation_2013-2014/TERG_Evaluation2013- 13. Pitt C, Greco G, Powell-Jackson T, Mills A: 2014ThematicReviewFragileStates_FramingDocume Countdown to 2015: assessment of official nt_en/]. development assistance to maternal, newborn, 25. Patel P, Cummings R, Roberts B: Exploring the and child health, 2003–08. Lancet 2010, 376:1485- influence of Global Health Initiatives on Health 1496. Systems in Conflict-Affected Countries: A Review of 14. Vassall A, Shotton J, Reshetnyk OK, Hasanaj- the Global Fund and the GAVI Alliance. Conflict Goossens L, Weil O, Vohra J, et al: Tracking aid and Health , in press. flows for development assistance for health. Glob 26. Spiegel PB, Bennedsen AR, Claass J, Bruns L, Health Action 2014, 7. Patterson N, et al: Prevalence of HIV infection in 15. Tol WA, Barbui C, Galappatti A, Silove D, conflict-affected and displaced people in seven sub- Betancourt TS, Souza R, Golaz A, van Ommeren M: Saharan African countries: a systematic review. Mental health and psychosocial support in Lancet 2007, 369:2187-2195.

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27. United Nations Security Council: Resolution 1960. UN Security Council; 2010, UN Doc S/RES/1960. doi:10.1186/1752-1505-9-S1-S2 Cite this article as: Tanabe et al.: Tracking 28. United Nations: About UNiTE. 2014 humanitarian funding for reproductive health: a [http://www.un.org/en/women/endviolence/about. systematic analysis of health and protection shtml]. proposals from 2002-2013. Conflict and Health 29. IASC Gender Marker: 2012 Gender Marker: 015 9(Suppl 1):S2. Analysis of Results and Lessons Learned. Geneva: UN OCHA; 2012. 30. Global Protection Cluster, Gender based Violence: What is the Genderbased Violence Area of Responsibility? 2014 [http://gbvaor.net/]. 31. Casey SE, Chynoweth SK, Cornier N, Gallagher MC, Wheeler EE: Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies. Conflict and Health 9(Suppl 1):S3. 32. Harmer A, Cotterrell L: Diversity in Donorship: The changing landscape of official humanitarian aid. Overseas Development Institute. London; 2005. 33. Communication with Julie Ann Thompson, Manager,, Financial Tracking Service, Common Humanitarian Action Planning Section, Program Support Branch, United Nations Office for the Coordination of Humanitarian Affairs: 2014.

Endnotes a Columns from FTS’ spreadsheets that were retained included: year; country/region; country/region code; appeal type; appeal title; project code; title; appealing agency; original requirements USD; revised requirements USD; funding USD; % covered; unmet requirements USD; and uncommitted pledges USD. b Overall, the analysis team spent between 30 seconds and 10 minutes to assess and categorize each proposal, depending on their relevance to reproductive health. The principal investigator conducted periodic, random comparison checks to ensure consistency in data analysis across the two Submit your next manuscript to BioMed Central analysts and over time. and take full advantage of: c The objectives of the MISP are to: 1) ensure effective • Convenient online submission coordination; 2) prevent sexual violence and manage • Thorough peer review its consequences; 3) reduce HIV transmission; 4) • No space constraints or color figure charges prevent excess maternal and neonatal morbidity and • Immediate publication on acceptance mortality; and 5) plan for comprehensive reproductive • Inclusion in PubMed, CAS, Scopus and Google Scholar health services. • Research which is freely available for redistribution

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54 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011

Abstract Objective: To provide information on trends on official development assistance (ODA) disbursement patterns for reproductive health activities in 18 conflict-affected countries. Design: Secondary data analysis. Sample: 18 conflict-affected countries and 36 non-conflict-affected countries. Methods: The Creditor Reporting System (CRS) database was analyzed for ODA disbursement for direct and indirect reproductive health activities to 18 conflict-affected countries (2002–2011). A comparative analysis was also made with 36 nonconflict-affected counties in the same ‘least-developed’ income category. Multivariate regression analyses examined associations between conflict status and reproductive health ODA and between reproductive needs and ODA disbursements. Main outcome measures: Patterns of ODA disbursements (constant U.S. dollars) for reproductive health activities. Results: The average annual ODA disbursed for reproductive health to 18 conflict-affected countries from 2002 to 2011 was US $ 1.93 per person per year. There was an increase of 298% in ODA for reproductive health activities to the conflict-affected countries between 2002 and 2011; 56% of this increase was due to increases in HIV/AIDS funding. The average annual per capita reproductive health ODA disbursed to least- developed nonconflict-affected countries was 57% higher than to least-developed conflict-affected countries. Regression analyses confirmed disparities in ODA to and between conflict-affected countries. Conclusions: Despite increases in ODA for reproductive health for conflict-affected countries (albeit largely for HIV/AIDS activities), considerable disparities remains. Keywords: Aid, conflict, ODA, reproductive health, war. Tweetable abstract: Study tracking 10 years of aid for reproductive aid shows major disparities for conflict- affected countries.

Introduction unintended pregnancies, maternal death and Reproductive health problems remain a disability, sexually transmitted infections leading cause of mortality and morbidity for (STIs) including HIV, and other problems women and girls of childbearing age related to their reproductive system and worldwide.1 Impoverished women, especially sexual behaviour.1 There is strong evidence those living in low- and middle-income of increased mortality and morbidity caused countries, suffer disproportionately from by poor access to reproductive health care in 55 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

all resource-poor countries but these tend to be worse in countries currently experiencing Box 1. Key definitions 2,3 Reproductive Health follows the definition armed conflict or recovering from it. It is given in the International Conference on estimated that 170 000 maternal deaths occur Population and Development in 1994.30 It yearly during humanitarian emergencies.4 The refers to the constellation of methods, majority of the top ten countries with the techniques, and services that contribute to highest maternal mortality ratios globally are reproductive health and wellbeing by 5 preventing and solving reproductive health experiencing or emerging from conflict. problems.31 Reproductive activities for Higher rates of maternal mortality are also conflict-affected populations such as refugees recorded in areas with recent conflict.6 In the and internally displaced persons include Democratic Republic of Congo, for family planning, HIV/AIDS and sexually transmitted diseases, maternal and newborn example, the contrast between the conflict- health, comprehensive abortion care, and affected eastern part of the country and the sexual and gender-based violence.12 Note: relatively peaceful western part of the the revised version of the Inter Agency Field country is stark, with maternal mortality Manual (2010) includes the following ratios of 1174 and 881 deaths per 100 000 components in reproductive health: family planning, maternal and newborn health, 7 live births, respectively. In many low- and comprehensive abortion care, preventing and middle-income countries, including conflict- responding to consequences of gender-based affected countries, women of reproductive violence, STIs, HIV and adolescent age are the main carers for children and reproductive health. Official development assistance (ODA) elderly relatives, and so mortality and is defined as flows of official financing morbidity associated with poor reproductive administered with the promotion of the health outcomes have profound long-term economic development and welfare of consequences for families and communities.8 developing countries as the main objective, Ensuring access to comprehensive health including humanitarian aid. ODA receipts comprise disbursements by bilateral donors information and services, including and multilateral institutions.32 reproductive health, is endorsed by United Humanitarian aid is assistance designed Nations Security Council Resolutions 1820, to save lives, alleviate suffering, and maintain 1888, 1889, 1960 and 1325, which are aimed and protect human dignity during and in the aftermath of emergencies and disasters. To at protecting women in conflict and post- be classified as humanitarian, aid should be conflict situations.9,10 These important consistent with the humanitarian principles resolutions include targeting gender-based of humanity, impartiality, neutrality and violence, which is often an intentional independence.33 strategy of war as well as a consequence of Conflict-affected countries include those that are currently engaged in war or those that increasing impunity in conflict-affected are defined as post-conflict countries. countries.11 Essential reproductive health Conflict-affected countries were selected as services and activities agreed by key having been in ‘war’ at a point in the period governmental, inter-governmental and non- 2000–2009 based upon the Uppsala University Conflict Database, with additional governmental agencies are contained in information used from the World Bank.34,35 leading humanitarian guidelines (summarised Conflict or War refers to violent armed in Box 1).12–15 56 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

family planning, remains low globally.22 In a struggle between hostile groups; there are over 1000 battle-related deaths in 1 year previous study we analysed ODA disbursed in our definition of conflict.36 Post-conflict for reproductive health activities in 18 is highly difficult to conceptualise and may conflict-affected countries between 2003 and refer to the period following a formal 2006.23 Our findings indicated that ODA was surrender, negotiated end of hostilities, or increasing for reproductive health to conflict- peace talks.37 It is a period with increased security and peace, although there may be affected countries but this was largely violence and insecurity in certain regions; attributable to increased funding for political and economic reforms and the influx HIV/AIDS activities, whereas ODA for of large-scale private investment and other reproductive health services was very development aid. Some countries are described as post- limited. The findings also showed lower conflict for up to two decades or more after absolute reproductive health ODA per capita the end of hostilities; however, this tends to to conflict-affected countries than be very context-specific depending on the comparable non-conflict-affected countries typology of conflict. Post-conflict peace is despite generally higher levels of typically fragile: nearly half of all civil wars are due to post-conflict relapses. 38 reproductive health needs. The study was useful for informing subsequent donor Investment in reproductive health is one policies on reproductive health in conflict- of the mosteffective ways to improve health affected countries.16,24–26 Further evidence of outcomes, promote equitable and sustainable long-term trends in reproductive health development and help alleviate poverty ODA distribution is useful in understanding across generations.2,16,17 Most reproductive how responsive aid is to levels of health interventions, such as family-planning reproductive health needs and to address services, are extremely cost-effective in issues of donor accountability and improving health outcomes and preventing transparency.27–29 maternal mortality and HIV.18,19 The The overall objective of this follow-up disruption caused by conflict and study is to provide information on longer- displacement reduces women’s and men’s term trends on ODA disbursement patterns access to family planning services.3 Recent for reproductive health activities in 18 studies have shown that the provision of conflict-affected countries. The specific comprehensive family planning services is objectives are1: to measure the absolute and widely accepted among conflict-affected per capita amount of reproductive health populations.20,21 ODA to conflict-affected countries;2 to Official development assistance (ODA) compare reproductive health ODA is a major source of the global financial disbursements to conflict-affected countries response for health in low- and middle- and non-conflict-affected countries;3 to income countries, including those currently analyse disbursement patterns of ODA affected by armed conflict and those which disbursement for different reproductive are defined as post-conflict (see definitions health-related activities;4 to analyse in Box 1). Evidence has shown that ODA for disbursement patterns of reproductive reproductive health activities, including health ODA by donors. 57 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

Methodology health initiatives such as the Global Fund to Data source fight AIDS, Tuberculosis and Malaria Aid data was extracted for 2002–2011 (GFATM) and the US President’s from the open-access Creditor Reporting Emergency Plan for AIDS Relief (PEPFAR). System (CRS) database, available at All bilateral and multilateral donors were http://stats.oecd.org/Index.aspx?datasetcod included in this study, as were all types of e=CRS1. CRS is maintained by the funding approaches. The CRS includes Development Assistance Committee (DAC) humanitarian aid; longer-term developmental of the Organisation of Economic programmatic or project funding; pooled Cooperation and Development (OECD). funding such as common humanitarian CRS data was determined to be the most funds for recipient countries; Sector-Wide comprehensive source of information on Approaches (SWAps) and basic packages of ODA for health and has been widely used health services; and general budget support. for research on tracking aid across different Bilateral and multilateral aid are recorded health sectors to all developing countries, separately in the CRS to avoid double- including those affected by conflict.39–46 CRS counting. covers an estimated 100% of aid This study did not include data from the disbursements from 2007, around 90% since Financial Tracking System (FTS) to avoid 2002.47 It ensures that there is little or no double-counting, as it does not provide double-counting; data are validated by a peer- additional data to that already included in review process. Reporting is mandatory for CRS. We contacted a number of specialists donors that use standard criteria, allowing for on humanitarian funding from CRS, FTS and comparability between donors and over Global Humanitarian Assistance to verify time.47,48 Other databases such as AidData that CRS analysis would cover all aid to offer less standardised data than CRS, which conflict-affected countries including non- uses the same data collection procedure earmarked funding allocated by donor across all donor agencies and is therefore countries to recipient countries, and considered to be the best data source for contributions to the Central Emergency studying trends in ODA from the same set Respond Fund (CERF), Common of donors over time.49 Humanitarian Fund (CHF) and Emergency The 18 countries selected for the study Response Fund (ERF). These emergency were those which met the definitions of funds are reported in CRS by the donor conflict-affected and/or post-conflict (Box countries to the recipient country and 1) and were the same as those used in the channelled through the United Nations first study so as to ensure continuity of Office for the Coordinator of Humanitarian analysis and to study longterm patterns of Affairs (UN OCHA), which is specified as 50 aid for reproductive health for these an aid channel flow. countries. The CRS includes ODA from 26 bilateral donors and 18 multilateral agencies Analysis including UN programmes and funds, World The methodology of analysing CRS follows Bank groups, regional banks, and global that used in our previous study.23 CRS- 58 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

labelled aid activities were selected that US$) were analysed for each of the 18 contributed either directly or indirectly to recipient countries for individual direct and reproductive health (Box 2). In the analysis, indirect reproductive health activities and for 100% of ODA disbursements for direct combined reproductive health. reproductive health activities were included: A comparative analysis of the total population policy and administration reproductive health ODA was also made management; reproductive health care with ODA disbursed to comparable non- (includes reproductive health promotion, conflict-affected countries. Of the 18 prenatal/postnatal/delivery care, safe conflict-affected countries, only three motherhood, fertility treatment, abortion countries were not in the OECD/DAC related care); family planning; personnel category of least-developed countries: development for population and Colombia, Iraq and Sri Lanka. We therefore reproductive health; social mitigation of compared the 15 conflict-affected countries HIV/AIDS; and STD control, including which were in the OECD/DAC category of HIV/AIDS. For the indirect activities, least-developed countries with the remaining proportions of ODA disbursements for the 36 non-conflict-affected countries in the following activities were allocated for least-developed country category.53 The inclusion in the analysis: education; basic methods described above for descriptively nutrition; general health; general budget analysing the data for conflict-affected support; humanitarian material relief countries were used for the 36 non-conflict- assistance and services; and reconstruction affected countries. We also examined the relief and rehabilitation (Box 2). This follows association between a country’s conflict the previously used approach.23,39,51,52 Donor status and receiving RH ODA disbursement contributions include both earmarked and through a series of multivariate linear non-earmarked grants (non-earmarked regression analyses. The outcomes related to funding means that the multilateral agency mean 2002–2011 per capita US$ RH ODA. has freedom to decide how the money is The exposure of interest was a binary used). All estimates were based on 2009 variable of ‘conflictaffected’ (i.e. the 15 constant US dollars, using CRS deflator rates conflict-affected least-developed countries) to adjust for changes in the exchange rate compared with non-conflict-affected (i.e. and inflation in the currency in which the the 36 nonconflict-affected least-developed flow occurred between the year of the flow countries). We modelled conflict status and the base year. against mean per capita RH ODA received All ODA data for each recipient country per disbursement in five separate regression selected for the study were downloaded from models using the following dependent the CRS and analysed in EXCEL and variables1: mean per capita overall RH STATA databases. Each of the CRS-labelled ODA;3 mean per capita direct RH ODA (see aid activities is accompanied in the CRS Box 2);3 mean per capita HIV/AIDS only database by a numeric ‘purpose-code,’ which ODA (purpose codes 13040 and 16064, see was used for the data analysis. The absolute Box 2);4 mean per capita reproductive health and per capita amounts of ODA (constant care ODA (purpose code 13020, see Box 2); 59 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

Box 2. Creditor reporting system activities included in the analysis Activities (purpose code) % Allocation Basis for allocation

Direct activities* Population policy & administration 100 Estimates based on calculations by the Netherlands Interdisciplinary management (13010) Demographic Institute (NIDI) and developed in the OECD 54th meeting Reproductive health care (13020)** 100 of the Working Party on Statistics, June 2005*** Family planning (13030) 100 Personnel development for population & 100 reproductive health (13081) Social mitigation of HIV/AIDS (16064) 100 STD control, including HIV/AIDS (13040) 100 Indirect activities Primary education (11220) 10 Estimates based on calculations by NIDI and developed in the OECD Basic skills for youth and education (11230) 10 54th meeting of the Working Party on Statistics, June 2005*** Early childhood education (11240) 10 Secondary education (11320) 10 Health policy & administrative 10 management (12110) Basic health care (12220) 25 Basic health infrastructure (12230) 25 Basic nutrition (12240) 75 Health education (12261) 25 Health personnel development (12281) 25 General budget support (51010) 2.11 Estimate based on average government expenditure on health for the 18 sampled countries (8.42%). **** 25% of this 8.42% was then allocated for RH based on NIDI estimates. Material relief assistance and services (72010) 1.94 Estimate based upon calculation of 7.76% of humanitarian ODA being Reconstruction relief and rehabilitation (73010) 1.94 allocated to the health sector using Financial Tracking Service data for 2003–2009. ***** 25% of this 7.76% was then allocated for RH, based on NIDI estimates.

*Direct RH categories based on categories defined in the 1994 ICPD and subsequently used in van Dalen H, Reuser M, Assessing size and structure of worldwide funds for population and AIDS activities, UNFPA/UNAIDS/NIDI Resource Flows Project, 2005, www.resourceflows.org/ index.php?module=uploads&func=download&fileId=99 (accessed 17 March 2015). **Reproductive health care includes promotion of reproductive health; prenatal and postnatal care including delivery; prevention and treatment of infertility; prevention and management of consequences of abortion; safe motherhood activities. ***de Bruijn & Horstman.52 ****Source: WHO (2007). World Health Statistics. Geneva: World Health Organization. *****Source: UNOCHA (2012). The Global Humanitarian Aid Database: Financial Tracking System. http://fts.unocha.org/ (accessed 17 March 2015).

and5 mean per capita family planning ODA S1 for these data and the sources. These were (purpose code 13030, see Box 2). To adjust all entered as categorical variables. Using for the potential confounding effect of backward stepwise elimination, we variables related to health outcomes, eliminated variables that were not statistically economic status and governance, we used a significant (P < 0.01) associated with our step-wise multivariate regression model. outcome, until we reached a model where First, we included the following independent every variable included was significantly variables in our model: key reproductive associated. Our final multivariate models are health indicators (HIV prevalence rate, adjusted for categories of HIV prevalence maternal mortality, and total fertility rate), rate, GDP per capita, government key economic data (GDP per capita) and effectiveness and control of corruption. We governance (government effectiveness and present here the association coefficients control of corruption) for each recipient reflecting the unit decrease/increase in the country – see Supporting Information Table continuous RH ODA outcomes according to 60 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

conflict status per disbursement. fertility rate which was again categorised The pattern of reproductive health ODA equally into tertiles. We used stepwise distribution and reproductive health needs to regression for each of these models, the individual conflictaffected countries were beginning first with the full range of possible explored descriptively through the use of confounders noted above and eliminating scatter plots for specific reproductive health those that were not statistically significantly indicators (indicator data taken from the associated with the outcome of interest (P < sources in Table S1) and the average annual 0.01). The confounders controlled for in (2002–2011) per capita ODA specifically for each final multivariate model are listed in their most closely related CRS purpose code Table 3. activity (see Box 2 for the purpose codes): HIV/AIDS prevalence and HIV/AIDS and Results STD control and social mitigation of The distribution of ODA for reproductive HIV/AIDS (purpose codes 16064 and health to the 18 conflict-affected countries is 13040 combined), maternal mortality rates shown in Table 1. ODA for reproductive and reproductive health care ODA (purpose health to the 18 conflict-affected countries code 13020); and total fertility rate and family increased by 298%, from US$ 303.5 million planning ODA (purpose code 13030). in 2002 to US$ 1,208.9 million in 2011 We also ran three multivariate linear (compared with a 178% increase in all regression models further to examine the ODA), with an annual average of US$ 747.0 association between reproductive ODA million disbursed to conflict-affected disbursements and reproductive health needs countries for reproductive health activities among all the conflict-affected countries during the study period. This equates to US$ combined while adjusting for potential 1.93 in reproductive health ODA per person confounders. The first model examined the per year to conflict-affected countries, 3% of association of a dependent continuous all ODA during the study period (annual variable of mean 2002–2011 per capita US$ average all ODA of US$ 24,568.5 million; ODA per disbursement for HIV/AIDS US$ 63.2 per capita; see Supporting (purpose codes 13040 and 16064) and HIV Information Table S2). The conflict-affected prevalence, with HIV prevalence data countries receiving the highest annual categorised into equal distribution quartiles average per capita reproductive health ODA to aid interpretation. The second model were Uganda (US$ 8.1), Timor-Leste (US$ examined the association of mean 2002– 6.7) and Liberia (US$ 5.4); and the countries 2011 per capita US $ ODA per disbursement receiving the lowest were Colombia (US$ for reproductive health care (purpose code 0.2), Myanmar (US$ 0.4), and Sri Lanka (US$ 13020) with maternal mortality, with 0.7). maternal mortality ratios categorised equally The distribution of reproductive health into tertiles. The third model examined the ODA disbursed to the 15 of the 18 conflict- association of mean 2002–2011 per capita affected countries which were classified as US$ ODA per disbursement for family ‘least developed countries’ was compared planning (purpose code 13030) with total with equivalent non-conflict-affected least 61 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851. ODA of all RH as % All ODA* Annual average ODA per RH capita (US $) ODA ng the period in question. 2011 – e; ODA, official development assistance; 2002 (US $ Million)* direct % from RH ODA** 2011 – 2002 2011 – 2011) from the direct RH ODA activities shown in table. – 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Mean 303.5289.1 412.0740.6 378.4 567.9 1028.3 511.3 1288.7 831.7 1486.4 670.6 831.7 1709.3 695.8 861.6 2135.6 1741.7 775.2 677.7 1939.0 640.1 864.0 2068.3 3136.2 820.6 911.3 1208.9 873.7 1727.4 1162.3 747.0 681.7 78.9 66.2 71.0 24 635.1 24 568.5 3.6 15 522.7 1.9 51.3 2.3 63.2 7.0 53.4 3.0 4.4 ODA disbursement to conflict-affected countries 2002 LDCs****** LDC Conflict***** Non-Conflict CAR, Central Africa Republic; DRC, Democratic Republic of the Congo; GDP, gross domestic product; LDC, least-developed countries; NA, not availabl AfghanistanAngolaBurundiCAR 24.6ChadColombia*** 42.0 26.1DRC 53.6Eritrea 9.9 30.9Iraq*** 67.0 4.2 11.8Liberia 7.0 25.8 18.4 78.4Myanmar 18.5 5.3 40.8Nepal 21.0 7.8 99.0 44.5 24.5Sierra 16.7 Leone 42.5 3.6 22.9 112.7 13.4Somalia 1.8 42.2 30.9 24.0 171.5 37.6Sri 12.0 Lanka*** 30.1 11.4 7.0 2.9 20.1 48.6Sudan 159.3 29.2 28.9 21.7 21.7 19.8 8.5 15.4Timor-Leste 11.1 35.5 45.6 185.4 4.6 73.0 15.0 28.6Uganda 22.9 22.5 14.0 137.9 8.3 43.0 9.8All 7.5 7.4 4.3 76.4 Conflict**** 23.2 9.2 16.6 99.3 100.7 18.5 34.9 7.6 41.8 15.3 8.1 83.3 2.2 2.6 5.0 33.2 4.2 10.4 12.2 19.6 62.9 32.7 17.8 48.8 19.9 50.9 69.5 7.8 47.6 64.3 11.2 7.4 12.5 3.4 4.9 3.8 21.7 4.8 9.1 24.3 29.9 65.2 15.7 92.8 99.5 20.0 16.1 21.3 8.6 25.3RH, 13.2 16.3 reproductive 24.4 5.9 6.0 4.6 health; 6.3 112.9 47.7 18.7 US 178.8All $, data US 3910.7 15.6 24.2 56.4 are dollars. 33.9 16.6 78.4 16.1 in 172.2Population constant 16.4 18.3 205.8 data US$ 9.8 5.8 48.6 12.5 from: with 6.1 US 2011 71.5*See Census as 26.1 16.0 63.3 Table Bureau the 12.7 18.5 218.5 S1 (www.census.gov/population/international/data/idb/informationGateway.php). base 3.7 for year, 18.4**Proportion 13.7 All using 56.0 29.5 ODA (%) deflator 81.5 13.4 8.1 of disbursements rates 298.1 26.9 mean 11.0 by used 50.6 9.2 7.0 144.7***Non-LDC RH year. by conflict-affected ODA CRS countries. (2002 to 8.2 44.3 44.5 incorporate 53.5 36.2 483.5****Total 258.5 donor for exchange 46.3 14.3 36.2 all rate 7.2 73.0 18 16.9 differences*****Total 58.2 conflict-affected 2.5 and 584.6 19.6 for countries 295.6 inflation the (both 67.1 40.3 duri 74.3 57.2 15 LDC******Total conflict-affected and 21.7 16.4 49.7 for countries non 1.9 36 in LDC). 314.1 6.1 non-conflict-affected the 17.3 2.3Data countries LDC in in category. 8.1 74.3 bold the 2.8 represent LDC 15.6 360.5 64.3 50.7 20.6 31.3 total category. amounts for the 74.7 4.9 3512.6 423.3 different 35.2 67.3 combined country 67.4 54.6 groupings. 245.8 229.4 891.2 6.2 13.7 12.1 72.6 68.0 7152.4 1.3 1.9 4.2 13.2 206.5 42.1 2.0 0.2 12.7 88.2 55.3 43.7 43.4 1.6 233.6 541.1 54.4 21.1 3.2 44.9 263.3 49.4 650.4 535.1 2.3 6.8 4.4 0.4 39.2 3.8 0.8 5.4 1973.0 0.6 1002.2 1.8 4.3 168.5 4.5 59.1 8.2 436.6 1514.1 110.2 8.1 23.5 0.7 3.2 9.3 69.7 3.9 1.5 49.1 1.4 7.8 271.8 11.6 48.2 49.1 1.4 6.7 3.0 2.8 267.9 2.5 Country RH ODA (US $ million) Mean All ODA Table 1.

62 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

Table 2. Regression analyses on association between countries being conflict-affected and mean per capita RH ODA (2002–2011)

RH ODA category model Bivariate models Multivariate models*

Coefficient 95% CI P Coefficient 95% CI P

All RH ODA model Non-conflict LDC Ref Ref Conflict-affected LDC À0.0018626 À0.00249; À0.00123 <0.001 À0.00021 À0.00043; À0.0000005 0.056 Direct RH ODA model Non-conflict LDC Ref Ref Conflict-affected LDC À0.0021908 À0.00296; À0.00142 <0.001 À0.00030 À0.00056; À0.00004 0.024 HIV/AIDS ODA model Non-conflict LDC Ref Ref Conflict-affected LDC À0.0019187 À0.00299; À0.00084 <0.001 À0.0000199 À0.00095; À0.000909 0.967 Reproductive health care ODA model** Non-conflict LDC Ref Ref Conflict-affected LDC 0.0011517 À0.00167; 0.003972 0.423 0.00205 0.00617; 0.00349 0.005 Family planning ODA model Non-conflict LDC Ref Ref Conflict-affected LDC 0.0003792 À0.0003; 0.001062 0.276 0.00119 0.00041; 0.00200 0.003

LDC, least developed country; ODA, official development assistance; Ref; reference category. *Each of the five multivariate regression models run separately after stepwise elimination of non-significant variables. All final models adjusted for HIV prevalence rate, GDP per capita, government effectiveness and control of corruption. **Reproductive health care includes reproductive health promotion, prenatal/postnatal/delivery care, safe motherhood, fertility treatment, abortion related care (see Box 2).

developed countries (Table 1).53 The data reproductive health ODA per disbursement show that the annual average per capita (B = 0.00030; P = 0.024), lower HIV/AIDS- reproductive health ODA disbursed to non- specific ODA per disbursement (B = conflictaffected least developed counties 0.00002; P = 0.967), but increased (US$ 3.60) was 57% higher than to least reproductive health care ODA per developed conflict-affected-countries (US$ disbursement (B = 0.00205; P = 0.05) and 2.30). In addition, 4.4% of all ODA increased family planning ODA per disbursed to conflict-affected least developed disbursement (B = 0.00119; P = 0.005). countries was for reproductive health The activities to which the reproductive activities, compared with 7.0% in non- health-related ODA to conflict-affected conflictaffected least developed countries. countries was disbursed are given in Box 2 The relation between countries being (and detailed in Supporting Information conflict-affected and levels of reproductive Table S3). Of the US$ 747 million disbursed health ODA disbursements was investigated on average per year to conflict-affected through the multivariate regression analysis countries for reproductive health activities, (Table 2). After adjustment for the potential two-thirds (66.2%) was for direct confounders, our findings suggest that being reproductive health activities. The data show a conflict-affected least developed country that an annual average of US$ 322.69 million (compared with a non-conflict-affected least was disbursed for HIV/AIDS activities developed country) is associated with (purpose codes for ‘HIV/AIDS and STD receiving lower per capita all reproductive control’ and ‘Social mitigation of health ODA per disbursement (B = 0.00021; HIV/AIDS’). This represents 43.2% of the P = 0.056), lower per capita direct US$ 747 million in ODA average annual 63 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

Table 3. Regression analyses on association of reproductive health ODA with reproductive health needs among conflict-affected countries

RH ODA category model* Bivariate Multivariate**

Coefficient 95% CI P Coefficient 95% CI P

Model 1: HIV/AIDS ODA ≤1.0% prevalence Ref Ref 1.01–2.0% prevalence 0.00070 À0.0012; 0.00261 0.469 0.003150 À0.0000009; 0.006309 0.051 2.01–10.0% prevalence 0.00184 0.00053; 0.00315 0.006 0.0000653 À0.002126; 0.00226 0.953 >10.0% prevalence 0.00484 0.00195; 0.00773 0.001 À0.00100 À0.01576; À0.00413 0.001 Model 2: Reproductive health care ODA*** MMR ≤650 Ref Ref MMR 651–1000 À0.00306 À0.00481; À0.0013 0.001 0.01911 0.0133; 0.02491 <0.001 MMR >1000 À0.00081 À0.00221; 0.00058 0.252 À0.01701 À0.02195; À0.01208 <0.001 Model 3: Family planning ODA TFR ≤4.50 Ref Ref TFR 4.51–5.9 À0.00018 À0.01098; À01062 0.974 À0.01027 À0.02286; 0.00232 0.110 TFR >6.0 0.00477 0.00059; 0.00895 0.025 0.01839 0.00138; 0.03540 0.034

MMR, maternal mortality ratio; ODA, official development assistance; Ref, Reference category; TFR; total fertility rate. *Mean 2002–2011 per capita US$ ODA for: HIV/AIDS only ODA (model 1); RH care only ODA (model 2); and family planning ODA (model 3). **Each of the three multivariate regression models run separately after stepwise elimination. Final Model 1 adjusted for maternal mortality ratio, fertility rate and government effectiveness. Final Model 2 adjusted for HIV prevalence, fertility rate, GDP per capita and government effectiveness. Final Model 3 adjusted for HIV prevalence, maternal mortality ration, GDP per capita and government effectiveness. ***reproductive health care includes reproductive health promotion, prenatal/postnatal/delivery care, safe motherhood, fertility treatment, abortion related care (see Box 2).

disbursements for reproductive health (direct latter generally appearing to have higher and indirect). The average annual ODA prevalences of HIV/AIDS and lower levels disbursed for direct reproductive health of other types of reproductive health needs activities, excluding HIV/AIDS activities, (Supporting Information Tables S1 and S4). was $172.2 million, or 23.0% of the average These relationships between mean per annual ODA disbursed for all reproductive capita reproductive health ODA health activities. The most significant disbursements (2002–2011) and reproductive disbursements for the non-HIV reproductive health needs are shown in the regression health activities were for reproductive health analyses in Table 3. The findings suggest a care (purpose code 13020) (13.3%) and basic general lack of response of reproductive health care (10.5%) (purpose code 12220). health ODA to reproductive health needs, Over half (56.3%) of the 298% increase in and in some categories of need for total reproductive health disbursements conflictaffected countries. Indeed, countries during the study period was due to the with a high maternal mortality ratio category substantial increase in HIV/AIDS funding. of >1000 had a negative association (B = Reproductive health care activities accounted 0.01701; P < 0.001) with reproductive health for 19.3% of the 298% increase. care ODA (purpose code 13020) when The dominance of HIV/AIDS funding compared with those with a lower maternal as a proportion of total reproductive health mortality ratio category of ≤650. Similarly, funding (direct and indirect) is greater in the countries with a higher HIV prevalence of conflict-affected least developed countries >10% had a negative association (B = (53.2%) than in the non-conflict-affected 0.00100; P = 0.001) with HIV/AIDS ODA least developed countries (39.5%) despite the (purpose codes 16064 and 13040 combined) 64 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

when compared with those with a lower Discussion prevalence category of <1.0%. However, Main findings ODA for family planning appeared to be There was a substantial increase (298%) in more responsive to need (B = 0.01839; P = ODA funding for reproductive health 0.03), with a higher total fertility rate category activities to the 18 conflict-affected countries (>6.0) associated with higher family planning between 2002 and 2011. This includes recent ODA (purpose code 13030) compared with increases in ODA for previously neglected a lower fertility rate category of ≤4.50. The topics such as family planning in 2008 and unadjusted patterns between per capita 2009. Similarly, ODA for the reproductive reproductive health ODA disbursements and health care category purpose code increased reproductive health needs for individual in 2008, 2009, 2010 and 2011, which countries are given in the scatter plots in addresses critical interventions such as Supporting Information Figure S1. These maternal health care. This perhaps reflects show that a number of countries (e.g. Chad, increasing advocacy and engagement Somalia, Central Africa Republic, and the in reproductive health humanitarian Democratic Republic of Congo) with high programming.13,54–56 However, the majority reproductive health needs receive of the increase in overall reproductive health considerably less per capita ODA than other funding during the review period is explained conflict-affected countries with lower by increased ODA for HIV/AIDS activities. reproductive health needs. This study also shows that non-conflict- The disbursement patterns by donor are affected leastdeveloped countries received provided in Supporting Information Table 57% more reproductive health ODA per S5. The donors disbursing the highest capita compared with the conflict-affected amount of absolute bilateral reproductive leastdeveloped countries during the decade health-related ODA were the USA (with reviewed, supporting findings from other increases in US ODA in 2008 and 2009 studies.57 After adjustment for potential largely accounting for the substantial increase confounding factors, the disparity largely in all reproductive health ODA to the remained. The new findings also show conflictaffected countries – albeit mostly for considerable aid disparity between conflict- HIV/AIDS), Japan, Germany and the UK. affected countries, with certain countries The bilateral donors disbursing the highest with extremely high reproductive health proportion of their ODA to reproductive needs (such as those with high maternal health were Ireland (9.3%), Denmark (5.1%) mortality and other health needs as shown in and Iceland (4.2%). Newer bilateral donors Table S1) receiving considerably fewer funds such as Czech Republic, South Korea and the compared with other countries with lower United Arab Emirates reported ODA for reproductive health needs. The regression reproductive health in CRS, but not in very analysis provides additional evidence of this significant amounts. Multilateral donors disparity between reproductive health needs disbursing the highest amount of absolute and ODA among conflict-affected countries, reproductive health-related ODA were the with the exception of family planning. World Bank and the European Union. Potential explanations for the disparity in 65 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

reproductive health funding towards Limitations conflict-affected countries include concerns There are a number of administrative over security, absorptive capacity and limitations with the CRS reporting system. governance in the recipient countries, and Our aid data review period (2002–2011) does varying media and policy attention. The not capture recent significant donor findings suggest there remains a substantial commitments for reproductive health such shortfall in ODA to meet reproductive health as the Global Strategy for Women’s and needs, which are estimated to be $70 billion Children’s Health to mobilise US$ 40 billion annually in 2015 globally.58,59 Resource to save the lives of 16 billion women and requirements for sustaining the current use children over 5 years, and other significant of contraception by 260 million women in donor pledges for family planning including the 69 poorest countries is estimated to be for post-conflict countries.60,62–64 However, approximately US$ 10 billion over 8 years complete disbursement data relating to these from 2012 to 2020.60 However, there are no pledges will not yet show in CRS. current reliable estimates of reproductive The CRS database does not include a health needs and related funding for purpose code for gender-based violence reproductive health activities in conflict- (GBV). Aid activities related to gender-based affected countries. Also, estimates of violence (GBV) are often also included in resource requirements for reproductive larger projects under human rights activities, health ODA in resource-poor countries are protection, elections and post-conflict peace- thought to be misleadingly low, as they do building activities. It is not possible to not take into account crucial service delivery apportion a percentage for GBV from these costs, which are likely to be higher in more general and large-scale projects. A conflict-affected countries because of separate purpose code for GBV would logistical challenges.61 enhance significantly understanding of patterns of aid allocations for this crucial Strengths issue.23 This study provides evidence of long-term For the CRS purpose code on ‘STD trends in reproductive health ODA control, including HIV/AIDS’, it not distribution for conflict-affected countries possible to disaggregate funding for HIV using the CRS reporting system. Analysis from other STDs and so we cannot examine presented in this study shows that there is funding for other STDs. We are also not able considerable disparity in the disbursement of to disaggregate funding for the reproductive health ODA between conflict- ‘Reproductive Health Care’ purpose code affected and non-conflict-affected countries (for example, for delivery care or (as well as between conflict-affected comprehensive abortion care). countries). The findings are useful in This study was limited to estimating understanding how responsive aid is to levels donor aid disbursements at national levels, so of reproductive health needs in conflict- it is not possible to know what proportion affected countries. of aid disbursement is spent on the ground and with which populations. We could not 66 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

therefore determine how ODA was significant amounts of humanitarian disbursed to conflict-affected regions and assistance), is not currently included in CRS. populations within each of the conflict- Studies suggest that the aid flows of such affected countries. This is especially relevant donors have nearly quadrupled, from an in conflict-affected countries as conflicts estimated 8.1% of total development tend to occur in geographically distinct areas assistance in 2000 to 30.7% of the total in (e.g. Sudan, Sri Lanka and northern Uganda). 2009.67,68 Aid from private, philanthropic and A related limitation is that South Sudan has non-governmental organisations is also not yet been included as a separate country excluded from our study, as most of these by CRS after becoming an independent state organisations do not currently report their in 2011, and so aid disbursements to South aid disbursements to CRS. The Bill and Sudan are included under Sudan. Melinda Gates Foundation has been It is difficult to estimate what percentage reporting some of its funding to CRS since of a country’s population is affected by 2009 under a private grants category. This conflict and how that may have changed over has not been analysed in this study as it does the study period. In addition, as rigorous and not constitute ODA and is not representative reproductive health data are comprehensive or standardised enough to insufficiently recorded with conflict-affected offer sufficiently reliable data on populations, we have been forced to use disbursements to conflict-affected national-level data for our models. There is a countries.69 Contributions from these critical need for more reproductive health emerging and large private donors have data specifically from conflict-affected become an increasingly relevant source of populations. There is also a need for in- financing in recent years, with some major depth, country- and local region-specific private donors rivalling many traditional research to investigate the ground-level multilateral and bilateral donors in terms of disbursement of reproductive health ODA. the scale of their funding. Global Countries affected by natural disasters Humanitarian Assistance provides analysis and/or undergoing political conflict, such as of funding from private organisations but it Syria, or transition, such as other Arab Spring is not possible to disaggregate their data into countries, have also been excluded from this sectors such as reproductive health.68 study in order to maintain a distinctive focus Increased aid reporting by private on countries affected by major armed organisations to a centralised data repository conflict during the study period from 2002 such as CRS would significantly enhance the to 2011. Several reports have described the efficiency and effectiveness of this important challenges of reproductive health in disaster- sector.39 affected countries and the Arab Spring Finally, although we used multivariate countries.65,66 Further studies are necessary to regression analysis to adjust for potential track ODA for these groups of countries. confounders when examining the Aid from other bilateral donors such as relationships between conflict status and the BRICS (Brazil, Russia, India, China, and reproductive health ODA and also between South Africa) and Turkey (which provides reproductive health needs and reproductive 67 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

health ODA, it is probable that there are Disclosure of interests unobserved confounders which may have a None declared. Completed disclosure of significant influence on these relationships. interests form available to view online as supporting information. Interpretation The findings suggest reproductive health aid Contribution to authorship disparities to and between conflict-affected PP conceptualised the paper and developed countries. In-depth, countryspecific research the study methodology, with contributions is required to investigate the supply and from BR, MD and MT. MD and BR demand characteristics of reproductive primarily conducted the data analysis, which health ODA. The findings from such was reviewed by AM. PP wrote the first draft research can help inform advocacy initiatives of the paper with contributions from BR. to improve donor accountability and co- MT, SG, LE contributed to the writing ordination, and ensure more equitable process. All authors reviewed and approved distribution of ODA to meet the the final text. reproductive health needs of populations affected by conflict. Details of ethics approval No ethical approval was required for this Conclusion study as all data used for the study is available The evidence presented in this study tracking in the public domain. 10 years of reproductive health aid disbursements suggests that although there Funding is some room for optimism from the This study was funded by the Bureau for increase in ODA for reproductive health for Population, Refugee and Migration and the conflict-affected countries from 2002 to MacArthur Foundation, through the 2011, the bulk of the increased funding is Women’s Refugee Commission. attributable to HIV/AIDS activities, and other reproductive health activities have not Acknowledgements benefited from such increases. Importantly, We would like to thank Louise-Lee Jones and there is also a disparity in the disbursement Catrin Schulte-Hillen. of reproductive health ODA between conflict-affected and non-conflict-affected Supporting Information countries (as well as between conflictaffected Additional Supporting Information may be countries). The funding inequities presented found in the online version of this article: in this study remain substantial obstacles for Figure S1. Maternal mortality and conflict-affected countries which remain reproductive health care ODA highly dependent on ODA and are the Table S1. furthest away from achieving the MDGs.70,71 Key reproductive health and socio-economic indicators for conflict- and non-conflict-affected least developed countries

68 Patel P, Dahab M, Tanabe M, Murphy A, Ettema L, Guy S, Roberts B. Tracking official development assistance for reproductive health in conflict-affected countries: 2002—2011. BJOG 2016; DOI: 10.1111/1471-0528.13851.

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RESEARCH Open Access Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies

Abstract Background: Reproductive health (RH) care is an essential component of humanitarian response. Women and girls living in humanitarian settings often face high maternal mortality and are vulnerable to unwanted pregnancy, unsafe abortion, and sexual violence. This study explored the availability and quality of, and access barriers to RH services in three humanitarian settings in Burkina Faso, Democratic Republic of the Congo (DRC), and South Sudan. Methods: Data collection was conducted between July and October 2013. In total, 63 purposively selected health facilities were assessed: 28 in Burkina Faso, 25 in DRC, and nine in South Sudan, and 42 providers completed a questionnaire to assess RH knowledge and attitudes. Thirty-four focus group discussions were conducted with 29 members of the host communities and 273 displaced married and unmarried women and men to understand access barriers. Results: All facilities reported providing some RH services in the prior three months. Five health facilities in Burkina Faso, six in DRC, and none in South Sudan met the criteria as a family planning service delivery point. Two health facilities in Burkina Faso, one in DRC, and two in South Sudan met the criteria as an emergency obstetric and newborn care service delivery point. Across settings, three facilities in DRC adequately provided selected elements of clinical management of rape. Safe abortion was unavailable. Many providers lacked essential knowledge and skills. Focus groups revealed limited knowledge of available RH services and socio- cultural barriers to accessing them, although participants reported a remarkable increase in use of facility-based delivery services. Conclusion: Although RH services are being provided, the availability of good quality RH services was inconsistent across settings. Commodity management and security must be prioritized to ensure consistent availability of essential supplies. It is critical to improve the attitudes, managerial and technical capacity of providers to ensure that RH services are delivered respectfully and efficiently. In addition to ensuring systematic implementation of good quality RH services, humanitarian health actors should meaningfully engage crisis- affected communities in RH programming to increase understanding and use of this life-saving care.

*Correspondence: [email protected] 2University of New South Wales, High St, Kensington NSW 2052, Australia Full list of author information is available at the end of the article

© 2015 Casey et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/ licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available 72 in this article, unless otherwise stated. Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

Background RH services for conflict-affected Reproductive health (RH) problems are a communities in Burkina Faso, Democratic leading cause of death and ill-health among Republic of the Congo (DRC), and South women and girls of childbearing age globally Sudan. The purpose of the study was to [1]. During conflict and natural disasters, document the current availability, quality, access to health services often decreases [2] utilization of, and access barriers to RH while RH needs increase [3]. By the end of services in selected humanitarian settings in 2013, an estimated 51.2 million people order to contribute to the evidence base remained forcibly displaced within their own informing humanitarian health-related policy country or as refugees [4]. As an essential and programming. component of humanitarian health response, addressing RH is critical to saving lives and Methods improving the wellbeing of these crisis- Study setting affected populations. The assessment sites included: the Seno, From 2002 to 2004, the Inter-agency Soum, and Oudalan provinces of the Sahel Working Group on Reproductive Health in Administrative Region in Burkina Faso, the Crises (IAWG) conducted a global evaluation Masisi Health Zone in North Kivu Province of RH in humanitarian settings [5]. The in DRC, and Maban County in South Sudan.b evaluation included a qualitative study on the Countries met at least three of the following availability, quality, and utilization of RH criteria: defined as low income by the World services in three humanitarian settings.a Bank classification in 2012; classified as Findings demonstrated that although RH “Warning” in the Failed States Index; was clearly on the agenda at a policy level, the experienced conflict during 2010-2012 per quality of services was variable. Researchers the Uppsala University Conflict Database; documented gaps in family planning (FP) defined as “Stressed,” “Crisis” or services, emergency obstetric and newborn “Emergency” on the Famine Early Warning care (EmONC), as well as services for HIV System; or had experienced a major natural and other sexually transmitted infections disaster that warranted the launch of a flash (STI). Response to gender-based violence appeal during 2011 or 2012. Within each (GBV) was the weakest area assessed, and country, site selection criteria included a internally displaced persons (IDPs)—as robust humanitarian health response and compared to refugees—were found to lack accessibility. critical access to RH care. Since 2004, some Although the study settings are all in sub- components of RH have been studied in Saharan Africa, they reflect different types of different humanitarian settings, but research humanitarian crises. The Sahel Region in remains limited [6]. Burkina Faso represents a more traditional From 2012 to 2014, IAWG undertook a displaced setting in which the majority second global evaluation of RH in of refugees (from Mali) reside in humanitarian settings. The present article three UNHCR-managed camps in an describes one component of this project: a impoverished yet stable rural setting [7]. In cross-sectional, mixed methods case study on volatile North Kivu, however, only 6% of 73 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

the IDPs live in camps [8]; both IDPs and Data on general infrastructure, financial host communities are affected by ongoing support, and human resources were also conflict. Maban County in South Sudan is a collected. The facility assessments used mixture of the two: the majority of refugees interviews with key staff, clinical register fleeing fighting in Sudan reside in four review, and room-by room inventory of UNHCR-managed camps, and the host essential supplies and equipment. A facility community itself is fragile with exceptionally was designated as capable of providing the poor infrastructure and episodic violence [9]. specific service based on the following criteria: services were provided in the Study design preceding three months (as self-reported by This cross-sectional, mixed methods case providers), skilled staff were in place (a mid- study improved on the 2004 evaluation by level provider or doctor who self-reported employing both a quantitative approach that training received), and minimum essential included assessments of health facilities equipment and supplies (described in the purposively selected from those providing respective sections) necessary to provide the services to crisis-affected populations as well services were in evidence on the day of the as an assessment of a convenience sample of assessment. The specific criteria for each providers’ knowledge and attitudes, and a service are detailed in the appendices. qualitative approach using focus group If a service had not been provided in the discussions (FGDs). The goal of the three prior months, facility staff were asked quantitative component was to document the to identify the primary reason from one of availability, quality, and utilization of RH three categories: 1) lack of staff or untrained service provision in the three settings. The staff; 2) lack of supplies, equipment, or purpose of the qualitative component was to drugs; or 3) lack of authorization (by MOH explore access barriers. or facility director) to provide the service. Data collection tools were adapted from Utilization of services was measured via existing tools by an IAWG working group service statistics from the six previous and translated into French. Ethical approval months. However, many of these data were was obtained through the Columbia missing due to poor registers or the absence University Institutional Review Board as well of key data points and were therefore as the Ministries of Health (MOH) in each excluded from this paper. setting. Informed verbal consent was In addition, self-completed close-ended obtained from all respondents. questionnaires were used to assess providers’ knowledge and attitudes about RH service Quantitative component provision to help determine quality of care. The quantitative component assessed health These findings are described in the text facilities with regards to availability, quality, whereas the data from the facility and utilization of FP services, EmONC, assessments are presented in the tables. comprehensive abortion care, as well as key aspects of clinical management of rape Qualitative component (CMoR), and HIV and other STI services. The qualitative component helped to identify 74 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

barriers to accessing care. The purpose of Pro version 5.0 and analyzed using SPSS the FGDs with community members was to version 21 (IBM Corp., Armonk, NY, USA); gather data on attitudes related to RH, qualitative data were analyzed using thematic knowledge of existing services, and analysis [10]. challenges to accessing RH services. Findings Data collection and analysis For each technical component of RH, we The assessments took place between July and first describe the facility assessment findings, October 2013. Data collectors participated including provider knowledge and attitudes. in a two-day training prior to data collection. We then describe the perceptions and For the quantitative data collection, a list responses from the FGDs. of all available health facilities serving both host and displaced populations (health General infrastructure center-level and above) was generated in each General infrastructure of health facilities was setting with the assistance of the respective assessed in terms of functioning power and MOH and UNHCR country offices. water supplies, supplies for minimum Facilities inaccessible due to insecurity and infection prevention, as well as the availability physical barriers, such as poor roads, were of at least one provider at night and on the excluded. All remaining facilities (63) were weekends (Table 2). Most of the hospitals assessed in each setting (Table 1). A had these elements in place whereas convenience sample of 42 providers at a availability at health centers varied. Supplies selection of facilities completed a for minimum infection prevention were questionnaire to assess knowledge and inconsistent across settings: two out of four attitudes. hospitals assessed and 50% or fewer of the For the qualitative component, a total of health centers had all supplies in evidence at 34 FGDs were held with 273 displaced the time of the assessment (Additional file 1: persons and 29 members of the host Appendix A). Few facilities (none in DRC; communities in groups of married women, two in South Sudan, and ten in Burkina Faso) married men, unmarried women and had at least one provider trained to provide unmarried men. Consecutive translation was adolescent friendly RH services. used; multiple facilitators took notes to Despite this, focus groups with refugees enhance triangulation (Table 1). residing in camps in Burkina Faso and South Quantitative data were entered into CS Sudan reported satisfaction with the health

Table 1 Data collectiony by method Facility Provider FGD: No. unmarried FGD: No. married FGD: No. unmarried FGD: No. married assessments assessment women women men men Burkina 28 11 21 20 16 20 Faso DRC 26 13 29 38 28 38 South 91820312120 Sudan Total 63 42 70 89 65 78

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Table 2 General infrastructure() (n=63 health facilities) Mean Mean At least 1 qualified health Functioning Functioning Minimum infection catchment number of provider available 24/7 power supply water supply prevention supplies2 population1 beds Burkina Faso (n=28)3 Hospital (n=3) 608,320 89 2 (66.7%) 3 (100%) 3 (100%) 1 ND* (1) Camp health 18,452 6 3 (100%) ND* (1) 2 (66.7%) ND* (1) 4 (100%) 0 center (n=4) ND* (1) Non-camp health 6,782 10 13 (61.9%) 13 (76.5%) ND* (4) 16 (80%) ND* (1) 5 (23.8%) center (n=21) DRC (n=26)4 Hospital (n=1) 378,000 171 1 1 1 1 Health center 12,870 8 18 (75%) 10 (40%) 14 (56%) 4 (16%) (n=25) South Sudan (n=9)5 Hospital (n=1) 209,700 60 ND* 1 1 0 Health center ND* 16 (range 1 (12.5%) 4 (50%) 8 (100%) 4 (50%) (n=8) 2-67) *ND = no data 1 Mean catchment population includes both host and displaced populations with the exception of the camp health facilities in Burkina Faso which served primarily refugees. 2 See Additional file 1: Appendix A for details on minimum infection prevention supplies. 3 The MOH manages three hospitals and 21 non-camp health centers while the four camp health centers are NGO-managed. The non-camp health centers primarily serve the host community whereas the camp facilities serve refugees. The hospitals serve both populations. 4 All facilities from DRC are MOH-managed, but the hospital and 15 health centers received some NGO support for health. 5 The hospital and one health center are MOH-managed, six health centers are NGO-managed, and one health center is managed by a religious mission.

services. They commented that facilities were (OCP), and injectable. Data on permanent within 30 minutes walking distance or FP methods and emergency contraception transport was available for emergencies. In (EC) after unprotected sex were also DRC, however, focus group participants collected. Functioning FP service delivery provided mixed feedback including some points were limited in Burkina Faso and complaints about the quality of care, such as DRC and nonexistent in South Sudan (Table clinic staff privileging people they know and 3). stock-outs of medicine and supplies. Access In South Sudan, five facilities reported was variable; non-camp focus groups providing OCPs and four reported providing reported the longest distance to a health injectables in the previous three months, yet facility, with one group reporting that the only one met the criteria to adequately nearest health center was two to three days’ provide these contraceptives; lack of supplies walk. Focus groups with displaced at the time of the assessment was the communities in all settings said health care primary reason for facilities failing to meet was free of charge. the criteria (Additional file 2: Appendix B). Permanent and long-acting methods were Family planning (FP) not available at any facilities, although one Functioning FP service delivery points health center reported having provided included the ability to adequately provide a implants in the previous three months. minimum method mix: intra-uterine device Providers cited all possible reasons: lack of (IUD), implant, oral contraceptive pill authorization, supplies, and trained staff. 76 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

Table 3 Functioning family planning (FP) service delivery point (n=63) Oral contraceptive pill Injectable IUD Implant Functioning FP service delivery (OCP) contraceptive point1 Burkina Faso (n=28) Hospital (n=3) 3 (100%) 3 (100%) 3 (100%) 3 (100%) 3 (100%) Camp health center (n=4) 3 (100%) 3 (100%) 1 (25%) 1 (25%) 1 (25%) ND* (1) ND* (1) Non-camp health center 17 (81%) 17 (81%) 1 (4.8%) 8 (40%) ND* (1) 1 (4.8%) (n=21) DRC (n=26) Hospital (n=1) 1 1 1 1 1 Health center (n=25) 12 (48%) 10 (40%) 9 (36%) 5 (20%) 5 (20%) South Sudan (n=9) Hospital (n=1) 0 ID** 0 0 0 Health center (n=8) 1 (12.5%) 1 (12.5%) 0 0 0 *ND = no data **ID = incomplete data. The hospital met all the indicators but data on availability of injectables at the time of the assessment were missing. 1 Defined as a facility able to provide IUDs, implants, OCPs, and injectables. A facility was classified as able to provide each method if the following criteria were met: self-reported provision of the service in the previous 3 months, at least one provider trained in FP service provision, and presence of minimum essential supplies and equipment on the day of the assessment. See Additional file 2: Appendix B for details.

Three facilities reported providing EC in the in both settings. For example, although all previous three months; scarce supplies and camp facilities and 90% of non-camp lack of authorization were the primary facilities in Burkina Faso reported providing reasons given for not providing EC. implants in the previous three months, only Questionnaires revealed that some providers one and 40%, respectively, had the minimum felt personal discomfort with FP services and essential supplies at the time of the had personal beliefs that may have influenced assessment, mainly due to lack of forceps. In their professional conduct. DRC, 72% of health centers reported In Burkina Faso and DRC, the four providing injectables in the three months hospitals met the requirements for a prior but only 54% had injectables in functioning FP delivery point (Table 3). evidence at the time of the assessment. Lack Among health centers in both settings, short- of trained staff was also a challenge to acting methods were more available than providing FP in DRC, while the large long-acting. In Burkina Faso, all camp majority of facilities in Burkina Faso had at facilities and 81% of non-camp health least one staff trained in each method. Some centers sufficiently provided short-acting permanent methods were available: the methods, yet only one of each met the hospital in DRC reported having performed criteria to provide IUDs and less than half tubal ligation and one hospital in Burkina adequately provided implants (Additional file Faso performed vasectomy in the previous 2: Appendix B). Among health centers in three months. Emergency contraception had DRC, coverage was variable with 48% reportedly been provided at 42% and 36% adequately providing OCPs and less than of facilities in DRC and Burkina Faso, half meeting the criteria to provide respectively, in the three months prior. injectables; 36% and 20% adequately Questionnaires found that some providers in provided IUDs and implants, respectively. all three settings maintained negative Insufficient supplies were a significant barrier attitudes toward women using contraception 77 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

without their husbands’ consent (Additional point when supplies and equipment were file 8: Appendix H). assessed (Table 4). Of the health centers, FGDs in all settings revealed significant only one in South Sudan could be defined as socio-cultural barriers and misconceptions a functioning BEmONC delivery point. In regarding FP. Participants reported that large DRC, the only adequately functioning families were socially valued, and BEmONC service delivery point was the contraception was associated with sex work hospital. Per WHO guidance, the minimum or sex outside of marriage, which were acceptable level of coverage is five viewed negatively. Further, awareness of functioning health facilities providing available services was limited in all settings. EmONC, at least one of which provides In DRC, some women reported that they CEmONC, per 500,000 population [11]. were required to present an authorization None of the settings met this benchmark for letter or be accompanied by their husband to minimum BEmONC or CEmONC access FP services, although no such policy coverage, although BEmONC coverage in was in place. Participants in Burkina Faso South Sudan was unknown because the and DRC said that unmarried and adolescent population was too transient to establish a women had the most difficulty accessing FP reliable mean health center catchment services, while in South Sudan, unmarried population. Facilities located in camps women were generally unaware of family reported functioning referral systems for planning methods. obstetric emergencies; however, non-camp facilities reported weaker or non-functional Emergency obstetric and newborn care referral mechanisms. (EmONC) Across settings, assisted vaginal delivery A functioning basic or comprehensive was particularly limited: of the health centers, EmONC service delivery point was defined one in DRC, three in South Sudan, and none as being able to provide the applicable signal in Burkina Faso were able to adequately functions,c or life-saving obstetric provide this signal function, primarily due to interventions, as recommended by WHO lack of authorization and absence of [11]; availability of partographs, blood supplies (Additional file 3: Appendix C). pressure cuff, and stethoscope, which are In Burkina Faso, the large majority of essential to provide good delivery care, were facilities had at least one provider trained to also required. In general, health centers provide BEmONC. Parenteral drugs were should provide basic EmONC (BEmONC) more available at non-camp health centers and referral hospitals comprehensive than camp centers, although the availability EmONC (CEmONC). Across settings, all of removal of retained products was hospitals except for one in Burkina Faso minimal at both with only one of each (which had not provided assisted vaginal adequately providing this signal function. In delivery) reported providing all elements of DRC, CEmONC was not fully available and CEmONC in the previous three months. Yet adequate BEmONC was extremely limited: only one hospital in Burkina Faso met the of the 26 health facilities, the hospital was criteria for a functioning CEmONC delivery the only adequately functioning EmONC 78 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

delivery point, and it only met the criteria as having provided neonatal resuscitation in the a BEmONC facility due to missing supplies previous three months, the availability of for blood transfusion. In South Sudan, most skilled staff trained to provide breastfeeding health centers sufficiently provided manual support, newborn infection management, removal of the placenta yet only two thermal care, cord care, kangaroo care, adequately provided parenteral delivery practices for prevention of mother- anticonvulsants; the referral hospital lacked to-child transmission of HIV (PMTCT), as elements to sufficiently provide assisted well as drugs for infection management. vaginal delivery and did not have Availability of adequate newborn care was partographs. Providers across settings limited across settings (Table 4). Of the reported a dearth of equipment and drugs as health centers that failed to provide adequate the primary barrier to providing adequate neonatal resuscitation in Burkina Faso and basic and CEmONC followed by shortages DRC, the majority reported lack of supplies of trained staff; some providers also as the main reason for not providing the reported that their facility lacked service: two-thirds did not have a authorization to provide certain signal resuscitation bag and infant face mask in functions. DRC and 80% lacked corticosteroids in Data on additional essential elements of Burkina Faso (Additional file 4: Appendix newborn care were also collected, including D). In addition, providers in many facilities

Table 4 Functioning EmONC and post-abortion care (PAC) delivery points, additional elements of newborn care, and induced abortion (n=63) Functioning BEmONC Functioning CEmONC Essential elements of Functioning PAC Induced service delivery point1 service delivery point1 newborn care2 service delivery point3 abortion4 Burkina Faso (n=28) Hospital (n=3) 1 (33.3%) 1 (33.3%) 2 (66.7%) 3 (100%) 0** Camp health 0 NA 1 (25%) 1 (25%) 0 center (n=4) Non-camp health 0 NA 2 (9.5%) 0 0 center (n=21) DRC (n=26) Hospital (n=1) 1 0* 1 1 0** Health center 0 NA 0 11 (44%) 0** (n=25) South Sudan (n=9) Hospital (n=1) 0 0 0 1 0 Health center (n=8) 1 NA 2 (25%) 1 0 ND (1) * Minimum criteria for all CEmONC signal functions met except for blood transfusion **Health facility assessments found that none of the facilities provided induced abortion. However, some providers reported that they had performed induced abortion in the previous three months. 1 Defined as a facility able to provide all nine (comprehensive) or seven (basic) EmONC signal functions. A facility was classified as able to provide each signal function if the following criteria were met: self-reported provision of EmONC services in the previous three months, at least one provider trained in basic or CEmONC, presence of minimum essential supplies and equipment for each signal function on the day of the assessment. See Additional file 3: Appendix C for details. Hospitals that met the criteria for a CEmONC facility are not included in the BEmONC data. 2 Defined as having at least one skilled staff trained to provide neonatal resuscitation, breastfeeding support, newborn infection management, thermal care, cord care, kangaroo care, delivery practices for PMTCT and presence of minimum essential equipment and supplies for neonatal resuscitation and infection management. See Additional file 4: Appendix D for details. 3 Defined as having provided PAC services in the previous three months (self-reported), offering FP to all PAC clients, presence of minimum essential equipment and supplies for PAC using MVA or misoprostol. See Additional file 5: Appendix E for details. 4 Self-reported provision of the service in the previous three months 79 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

across settings lacked training in newborn met the criteria to adequately provide PAC. infection management. Fewer health centers in Burkina Faso and Provider questionnaires revealed varied South Sudan sufficiently provided PAC, with knowledge of EmONC. For example, on providers reporting they were unauthorized average across settings, providers could name to do so. Providers in all settings also cited most of the nine key observations for labor scarce supplies followed by dearth of trained monitoring but fewer than half of the eight staff as barriers to service provision. MVA essential activities to manage post-partum was the most common means of uterine hemorrhage (Additional file 8: Appendix H). evacuation; and two facilities in Burkina Faso Despite the significant gaps in good and three in both DRC and South Sudan had quality EmONC services, focus groups and misoprostol for PAC available at the time of community leaders reported positive the assessment (Additional file 5: Appendix experiences with maternal health services. E.) Notably, all groups—including men—in the Although induced abortion is legally three settings were aware of the advantages permitted under certain circumstancesd in all of women delivering in a health facility. settings [13], the facility assessments found Remarkably, whereas childbirth had that none of the facilities provided this previously occurred at home with a service. However, interviews with providers traditional birth attendant, respondents and the questionnaires suggested that reported that facility births had now become abortion may be available at some health a norm. They attributed their attitude and facilities in DRC and Burkina Faso, although behavior changes to education campaigns this remains unclear. Providers in all settings and outreach by health providers. In all reported that their facility lacked settings refugees and IDPs said that they authorization to perform induced abortions were aware of the existing maternal health and few staff were trained. Across settings, services and that care was free. One FGD in FGDs revealed negative attitudes toward DRC reported that distance impeded access abortion, which they said conflicted with to delivery care. religious beliefs. However, all reported that some women and girls in their communities Comprehensive abortion care resorted to unsafe abortion. Comprehensive abortion care included the provision of post-abortion care (PAC) as Clinical management of rape (CMoR) well as safe induced abortion according to While the minimum package of CMoR for national law [12]. Of the five hospitals low-resource settings includes 25 elements assessed, all met the requirements for a [14], selected key elements of CMoR were functioning PAC service delivery point, assessed, including the availability of EC, defined as being able to adequately provide post-exposure prophylaxis for HIV (PEP), manual vacuum aspiration (MVA) or and antibiotics for STI prevention, the misoprostol and offering at least one FP provision of these drugs in the previous method to post-abortion clients (Table 4). three months, as well at least one staff Among health centers, almost half in DRC trained to provide CMoR. 80 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

Table 5 Facilities with essential drugs and at least 1 qualified staff to provide clinical management of rape (CMoR) (n=63)

At least 1 provider Post-exposure Emergency Antibiotics to Facilities with essential drugs and qualified to provide prophylaxis (PEP)1 contraception prevent STI1 ≥1 qualified staff for CMoR CMoR (EC)1 Burkina Faso (n=28) Hospital (n=3) 2 (66.7%) 2 (66.7%) 0 2 (66.7%) 0 Camp health 1 (33.3%) 0 2 (67.7%) ND* (1) 2 (50%) 0 center (n=4) ND* (1) Non-camp health 10 (47.6%) 0 6 (28.6%) 9 (42.9%) 0 center (n=21) ND* (1) DRC (n=26) Hospital (n=1) 1 1 1 1 1 Health center 18 (72%) 10 (40%) 12 (48%) 2 (8%) 2 (8%) (n=25) South Sudan (n=9) Hospital (n=1) 0 0 0 0 0 Health center 1 (25%) 1 (14.3%) 1 (14.3%) 2 (28.6%) 0 (n=8) ND* (4) ND* (1) ND* (1) ND* (1) ND* (2) *ND = no data 1 Self-reported provision of the service in the previous three months and presence of supplies on the day of the assessment. See Additional file 6: Appendix F for details.

Across settings, only three facilities, all in provided EC and antibiotics for STIs as part DRC, had these selected elements in place of CMoR in the previous three months; (Table 5). Some availability of this care in three of the four reported providing PEP. In DRC—as opposed to the other two South Sudan, two health centers reported settings—was not surprising given the providing all drugs—EC, PEP, and international attention to the widespread antibiotics for STIs—for CMoR in the prior sexual violence in DRC’s conflict-affected three months. Yet, at the time of the areas [15]. Yet three of 26 facilities still assessment, all lacked supplies. In Burkina constituted limited coverage, and it was Faso, PEP was not available at any health unclear whether these three facilities centers; of the health centers that did not provided all components of the minimum provide PEP in the previous three months, package of CMoR [14]. A paucity of drugs half reported that they were not authorized was the primary barrier reported in DRC. to do so. For instance, more than 80% of facilities Regarding staff, almost three quarters of reported providing presumptive STI health facilities in DRC had at least one treatment for CMoR in the previous three provider trained in CMoR. Trained providers months, but only 8% had all necessary were less available in Burkina Faso and South antibiotics for STIs available on the day Sudan. Questionnaires demonstrated that, on of the assessment (Additional file 6: average, providers across settings could Appendix F). identify fewer than half of the eleven key A dearth of supplies was found in the CMoR activities (Additional file 8: Appendix other two settings as well. In Burkina Faso, H). all four camp facilities reported having Responses from FGD participants about

81 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

sexual violence varied. Participants in DRC previous three months, yet, apart from non- were the most knowledgeable about where camp facilities in Burkina Faso, the majority to seek services and were generally aware of failed to meet the criteria to adequately the importance of seeking care within 72 provide these services due to lack of hours after rape. Informants in South Sudan antibiotics (Additional file 7: Appendix G). and Burkina Faso were unaware of existing In South Sudan, ARVs for PMTCT and ART services or reasons to seek health care. had not been provided at any health facility However, across settings, the FGDs reported in the previous three months; six of the nine that most rape survivors would not come health facilities reported that they lacked forward due to fears of stigma and rejection authorization to administer ARVs and others as well as concerns about confidentiality. All reported they lacked supplies. In DRC, none said that young unmarried women were at of the health centers adequately provided risk of sexual assault. Women in DRC PMTCT due to lack of supplies as well as reported that sexual violence was lack of trained staff. In Burkina Faso, most widespread, including at home and by armed services were available in non-camp facilities; groups. Women in Burkina Faso and South however, ART outside of the hospitals was Sudan described marital rape as rarely available, primarily due to policy commonplace; they reported that sexual barriers, with 18 of the 25 health centers violence outside of marriage did occur, reporting they were not authorized to primarily perpetrated by members of the provide ART to PLHIV. Questionnaires refugee or host communities, but was rare. revealed that, on average across settings, providers could name half of five key HIV and other STIs elements of care for someone presenting Adequate provision of STI services with symptoms of an STI (Additional file 8: (syndromic or laboratory testing and Appendix H). treatment) and PMTCT included self- Most FGD participants had heard about reported provision of the service in the HIV yet stigma and misconceptions preceding three months and the availability abounded. Condom knowledge and use, of essential drugs on the day of the which focus group participants often assessment. Data were collected on self- associated with sex workers, was low. reported provision of anti-retroviral therapy Although condoms were provided at roughly (ART) for people living with HIV (PLHIV), half of the health facilities in South Sudan voluntary counseling and testing for HIV and DRC and more than three quarters in (VCT), and condoms in the previous three Burkina Faso, only in Burkina Faso were the months. majority of FGD participants aware of their Adequate STI and HIV services were availability. In all sites, young unmarried available at the hospital in DRC and two of women were the least knowledgeable of three hospitals in Burkina Faso, but HIV, STIs, and ways to minimize nonexistent at the hospital in South Sudan transmission; some young women in DRC (Table 6). Most facilities across settings had never heard of HIV or AIDS. reported having provided STI care in the Participants in Burkina Faso and DRC cited 82 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

Table 6 HIV and other sexually transmitted infection (STI) services (n=63) y Syndromic or laboratory ARVs for HIV+ mothers and ART for people Voluntary HIV Condom diagnosis and treatment of STIs1 newborns in maternity1 living with HIV2 counseling and provision2 testing2 Burkina Faso (n=28) Hospital (n=3) 2 (67%) 3 (100%) 3 (100%) 3 (100%) 3 (100%) Camp health 1 (25%) 1 (25%) 1 (25%) 4 (100%) 3 (75%) center (n=4) Non-camp health 21 (100%) 18 (90%) ND* (1) 3 (14.3%) 19 (90.5%) 18 (85.7%) center (n=21) DRC (n=26) Hospital (n=1) 1 1 1 1 1 Health center 2 (9%) 0 1 (4%) 6 (25%) 12 (48%) (n=25) ND (2) South Sudan (n=9) Hospital (n=1) 0 0 0 0 0 Health center 3 (38%) 0 0 1 (12.5%) 4 (50%) (n=8) *ND = no data 1 Self-reported provision of the service in the previous three months and presence of essential equipment and supplies on the day of the assessment. See Additional file 7: Appendix G for details. 2 Self-reported provision of the service in the previous three months

lack of confidentiality as a key barrier to to adequately provide them: many facilities seeking HIV/AIDS services. reported having recently provided a number of RH services, yet—apart from the Discussion hospitals in DRC and Burkina Faso—the A decade has passed since the availability, availability of a minimum standard of quality quality, and barriers to RH services have RH services was generally limited. A service been assessed across crisisaffected settings. cannot be considered available when Although poor data quality prevented minimum essential elements to provide the analysis of utilization data, the mixed service are not present or face regular stock- methods approach allowed us to estimate outs. Further, many providers lacked critical quality of care through the availability of a RH knowledge and some exhibited biases minimum standard of RH services and that weakened good quality care. provider knowledge and attitudes, as well as Compared to findings from other understand access barriers. research in humanitarian settings, [5,6,16] The assessment criteria held facilities to positive developments were evident in all a strict minimum standard of care, based on settings: some health facilities are meeting international guidance, requiring them to minimum standards. Among those that did have provided the service recently as well as not meet minimum standards for specific have trained staff and specific essential RH components, all facilities reported recent, supplies in place. Findings revealed a striking albeit inadequate, provision of some RH inconsistency between the self-reported services, indicating RH programming is provision of RH services and the availability being implemented but facilities need of the minimum supplies and trained staff assistance to meet standards. Low-income 83 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

settings with weak or limited RH services serious gaps—did not meet the criteria for before the crisis can benefit from even a basic EmONC facility nor did it offer humanitarian interventions. The three any FP methods, including condoms. countries for this study have consistently Misconceptions and cultural barriers ranked low on the Human Development regarding FP were widespread, and many Index: South Sudan (as part of Sudan) was providers avoided discussing the topic with ranked 171 out of 186 in 2013, Burkina Faso clients. In sub-Saharan Africa generally, an was 183, and DRC tied for last [17]. Their estimated 97% of abortions are unsafe [24]. weak health systems suggest that many RH Concurrently, findings show that safe services are not available to the general abortion was not systematically available in population, and humanitarian agencies have any assessment sites, and availability of PAC contributed to decentralizing services to rural and a full package of FP services were areas that may otherwise take decades to limited in health centers. This deadly receive such support. For example, an combination of high RH needs, limited and assessment in North Kivu in 2002 found that poor quality care, lack of knowledge, and condoms were generally not available at cultural barriers that thwart health-seeking health facilities and only one facility assessed behavior demands urgent attention. offered VCT for a fee [18]. Now the hospital The findings highlight that, in addition and some health facilities in the Masisi to expanding RH service provision, attention Health Zone provide free VCT and is needed to ensure services are of good condoms. Further, displaced communities in quality and meet minimum standards; all sites reported significant changes in sociocultural access barriers to all RH delivery practices: previously women had components also need addressing. The poor given birth at home whereas they now availability of utilization data (e.g., service sought facility-based care. These positive statistics) underscores the importance of behavioral developments resulted largely using data to improve services. When from outreach by humanitarian actors. services are introduced, attention must be The study also found a number of paid to ensure that key data are collected in critical gaps in service provision, which are facility registers so staff can monitor particularly worrying when situated against progress. Among other recommendations the backdrop of the RH needs in the three outlined below, health actors must prioritize settings. Only three of the 25 health centers and support RH programming and ensure assessed in DRC provided all assessed RH is integrated into their primary health elements of CMoR, despite extensive sexual care activities. violence documented in the area [19-22]. In South Sudan, 2,054 women die of Community engagement pregnancy-related causes per 100,000 live Findings from FGDs highlighted the births and have an average of 6.7 children, importance of community engagement. among the worst maternal mortality and Across settings, many refugees and IDPs highest fertility rates in the world [23]. The reported being unaware of existing RH South Sudan county hospital—among other services or lacking information as to why 84 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

they should seek care. For example, many months. FGD participants did not know that Adequate STI and HIV services were medicine to decrease risk of pregnancy or available at the hospital in DRC and two of HIV transmission than half of the eleven three hospitals in Burkina Faso, but key CMoR activities (Additional file 8: nonexistent at the hospital in South Sudan Appendix H). (Table 6). Most facilities across settings Responses from FGD participants about reported having provided STI care in the sexual violence varied. Participants in DRC previous three months, yet, apart from non- were the most knowledgeable about where camp facilities in Burkina Faso, the majority to seek services and were generally aware of failed to meet the criteria to adequately the importance of seeking care within 72 provide these services due to lack of hours after rape. Informants in South Sudan antibiotics (Additional file 7: Appendix G). and Burkina Faso were unaware of existing In South Sudan, ARVs for PMTCT and ART services or reasons to seek health care. had not been provided at any health facility However, across settings, the FGDs reported in the previous three months; six of the nine that most rape survivors would not come health facilities reported that they lacked forward due to fears of stigma and rejection authorization to administer ARVs and others as well as concerns about confidentiality. All reported they lacked supplies. In DRC, none said that young unmarried women were at of the health centers adequately provided risk of sexual assault. Women in DRC PMTCT due to lack of supplies as well as reported that sexual violence was lack of trained staff. In Burkina Faso, most widespread, including at home and by armed services were available in non-camp facilities; groups. Women in Burkina Faso and South however, ART outside of the hospitals was Sudan described marital rape as rarely available, primarily due to policy commonplace; they reported that sexual barriers, with 18 of the 25 health centers violence outside of marriage did occur, reporting they were not authorized to primarily perpetrated by members of the provide ART to PLHIV. Questionnaires refugee or host communities, but was rare. revealed that, on average across settings, providers could name half of five key HIV and other STIs elements of care for someone presenting Adequate provision of STI services with symptoms of an STI (Additional file 8: (syndromic or laboratory testing and Appendix H). Most FGD participants had treatment) and PMTCT included self- heard about HIV yet stigma and reported provision of the service in the misconceptions abounded. Condom preceding three months and the availability knowledge and use, which focus group of essential drugs on the day of the participants often associated with sex assessment. Data were collected on self- workers, was low. Although condoms were reported provision of anti-retroviral therapy provided at roughly half of the health (ART) for people living with HIV (PLHIV), facilities in South Sudan and DRC and more voluntary counseling and testing for HIV than three quarters in Burkina Faso, only in (VCT), and condoms in the previous three Burkina Faso were the majority of FGD 85 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

participants aware of their availability. In all Compared to findings from other sites, young unmarried women were the least research in humanitarian settings, [5,6,16] knowledgeable of HIV, STIs, and ways to positive developments were evident in all minimize transmission; some young women settings: some health facilities are meeting in DRC had never heard of HIV or AIDS. minimum standards. Among those that did Participants in Burkina Faso and DRC cited not meet minimum standards for specific lack of confidentiality as a key barrier to RH components, all facilities reported recent, seeking HIV/AIDS services. albeit inadequate, provision of some RH services, indicating RH programming is Discussion being implemented but facilities need A decade has passed since the availability, assistance to meet standards. Low-income quality, and barriers to RH services have settings with weak or limited RH services been assessed across crisis affected settings. before the crisis can benefit from Although poor data quality prevented humanitarian interventions. The three analysis of utilization data, the mixed countries for this study have consistently methods approach allowed us to estimate ranked low on the Human Development quality of care through the availability of a Index: South Sudan (as part of Sudan) was minimum standard of RH services and ranked 171 out of 186 in 2013, Burkina Faso provider knowledge and attitudes, as well as was 183, and DRC tied for last [17]. Their understand access barriers. weak health systems suggest that many RH The assessment criteria held facilities to services are not available to the general a strict minimum standard of care, based on population, and humanitarian agencies have international guidance, requiring them to contributed to decentralizing services to rural have provided the service recently as well as areas that may otherwise take decades to have trained staff and specific essential receive such support. For example, an supplies in place. Findings revealed a striking assessment in North Kivu in 2002 found that inconsistency between the self-reported condoms were generally not available at provision of RH services and the availability health facilities and only one facility assessed of the minimum supplies and trained staff offered VCT for a fee [18]. Now the hospital to adequately provide them: many facilities and some health facilities in the Masisi reported having recently provided a number Health Zone provide free VCT and of RH services, yet—apart from the condoms. Further, displaced communities in hospitals in DRC and Burkina Faso—the all sites reported significant changes in availability of a minimum standard of quality delivery practices: previously women had RH services was generally limited. A service given birth at home whereas they now cannot be considered available when sought facility-based care. These positive minimum essential elements to provide the behavioral developments resulted largely service are not present or face regular stock- from outreach by humanitarian actors. outs. Further, many providers lacked critical The study also found a number of RH knowledge and some exhibited biases critical gaps in service provision, which are that weakened good quality care. particularly worrying when situated against 86 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

the backdrop of the RH needs in the three outlined below, health actors must prioritize settings. Only three of the 25 health centers and support RH programming and ensure assessed in DRC provided all assessed RH is integrated into their primary health elements of CMoR, despite extensive sexual care activities. violence documented in the area [19-22]. In South Sudan, 2,054 women die of Community engagement pregnancy-related causes per 100,000 live Findings from FGDs highlighted the births and have an average of 6.7 children, importance of community engagement. among the worst maternal mortality and Across settings, many refugees and IDPs highest fertility rates in the world [23]. The reported being unaware of existing RH South Sudan county hospital—among other services or lacking information as to why serious gaps—did not meet the criteria for they should seek care. For example, many even a basic EmONC facility nor did it offer FGD participants did not know that any FP methods, including condoms. medicine to decrease risk of pregnancy or Misconceptions and cultural barriers HIV transmission after rape or intercourse regarding FP were widespread, and many existed. Even those who knew about the providers avoided discussing the topic with existing services—and the importance of clients. In sub-Saharan Africa generally, an accessing care—disclosed that they were estimated 97% of abortions are unsafe [24]. unlikely to seek care at a health facility. Concurrently, findings show that safe Cultural norms, such as the relationship abortion was not systematically available in between social status and number of any assessment sites, and availability of PAC children, as well as social sanctions against and a full package of FP services were PLHIV, rape survivors, and women who use limited in health centers. This deadly FP methods undermined health-seeking combination of high RH needs, limited and behavior. Some FGDs also expressed poor quality care, lack of knowledge, and concerns about confidentiality and the cultural barriers that thwart health-seeking quality of existing RH services. behavior demands urgent attention. Some providers did not recognize the The findings highlight that, in addition need to expand specific RH services, and to expanding RH service provision, attention only provided care—particularly FP is needed to ensure services are of good methods—to clients who specifically quality and meet minimum standards; requested it. Low use of RH services does sociocultural access barriers to all RH not reflect a true lack of demand but components also need addressing. The poor indicates a need for education and availability of utilization data (e.g., service engagement as well as integration of RH statistics) underscores the importance of with other health services. Provider training using data to improve services. When and awareness-raising of service availability services are introduced, attention must be are good first steps but insufficient. paid to ensure that key data are collected in Meaningful community participation and facility registers so staff can monitor engagement, grounded in a rights-based progress. Among other recommendations approach and evidence-informed 87 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

programming, are necessary to increase necessary to realize these recommendations. access to and use of RH services. Indeed, the The establishment of a functioning beneficial changes in community norms and commodity management system is essential behaviors regarding facility-based delivery to ensure consistent access to care. resulted from systematic outreach by health actors. A small yet robust body of evidence Capacity development suggests that community participation in Gaps in RH care resulted from a dearth of primary health care is associated with skilled staff as well. Primary training gaps increased utilization as well as improved included long-acting and permanent FP health outcomes [25]. These findings provide methods, newborn infection management, support that community engagement is not adolescent-friendly services, induced just desirable but essential for successful RH abortion, and assisted vaginal delivery. Few service implementation. staff in Burkina Faso and South Sudan had training in CMoR. Further, questionnaires Commodity security revealed that, even when trained providers Poor commodity security and supply chain were in place, many lacked essential management obstructed good quality service knowledge and skills. An effective, good delivery in all settings. Providers quality humanitarian health response requires overwhelmingly reported a paucity of drugs skilled staff with an up-to-date knowledge as the primary barrier to providing adequate and skills base. Health staff providing RH RH care. Further, many facilities reported services need competency- based clinical providing RH care yet lacked sufficient trainings on RH as well as health systems equipment and supplies to adequately do so. broadly. Shortcomings in health service Action to address commodity security and provision result not only from weak clinical management is urgently needed. As a starting competence but also from lack of non- point, a comprehensive logistical audit, technical skills such as poor situation including evaluation of policy and protocols, awareness, decision-making, and inter- budgetary constraints, forecast accuracy, personal skills including communication and storage conditions, and staff capacity would teamwork. These social and cognitive skills benefit RH provision in the three settings. can increase patient safety and streamline Capacity development of national and service delivery; moreover, these skills can be international staff at every point in the taught and learned [26]. Clinical trainings supply chain as well as improved logistics should integrate these important elements as management information systems can help well as reinforce humanitarian principles, strengthen the delivery system. Where professional ethics, and accountability to feasible, respective MOHs should establish affected communities—cornerstones of or strengthen contingency stocks of RH good quality health care. Supportive supplies to prevent stock outs. Evidence- supervision should be practiced to help based advocacy may be required to integrate providers improve and maintain these skills RH commodity security into national policies and address gaps in service provision. and programs. Finally, sustained funding is 88 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

Policy address restrictive policies and discrepancies Restrictive national policies as well as between policy and practice. providers’ lack of knowledge of supportive policies and protocols undermined RH Adolescent RH service provision. Providers at health centers Across settings, few facilities had at least one reported that lack of authorization provider trained to provide adolescent- significantly restricted the provision of friendly RH services. Focus groups revealed assisted vaginal delivery, CMoR, and ART, that young unmarried women were least especially in Burkina Faso. Mid-level knowledgeable about HIV, STIs, and providers should be allowed to provide many condom use compared to unmarried men, RH services, such as all elements of married men, and married women. They BEmONC, to expand service availability at were the least likely to seek FP services, and the health center level [27]. As far as we FGDs reported that young women were could determine, health centers in the three among the most vulnerable to sexual assault. countries are mandated to provide all Communities expressed fears that making assessed RH services except for surgery, contraceptives available to adolescents would blood transfusion, safe abortion, and in some increase sexual activity outside of marriage. cases initiation of ART, suggesting incorrect Adolescents in developing countries are knowledge of MOH policies by those who more likely to marry younger, resort to cited a lack of authorization for many unsafe abortion, and die in childbirth than services. their counterparts in wealthier nations [33]. Safe abortion was an alarming gap across Adolescents in crisis-affected settings have all facilities. In the three countries, abortion additional vulnerabilities, risks, and needs is legally permitted when the woman’s life is [34]. In North Kivu, for example, only 9% at risk; Burkina Faso has additional legal of women and girls aged 15-24 reported indications for abortion [13]. Yet almost all using a condom the last time they had sexual providers reported that abortion was intercourse with a casual partner [35]. unauthorized in their facility. Although According to a review of adolescent RH international guidance on RH in emergencies programs in humanitarian settings, successful includes safe abortion to the extent of the programs ensure adolescent participation in law [12,28,29], abortion has largely been programming, work to build community ignored by humanitarian health actors trust and adult support, and secure qualified [30,31]. An estimated 13% of all maternal and dedicated staff [34]. Findings deaths are caused by unsafe abortion demonstrate need for adolescent-specific globally; more than 98% occur in the world’s interventions in the three settings. poorest countries, where the majority of humanitarian emergencies occur [32]. Limitations Respective MOHs as well as international This study faced a number of limitations. humanitarian health actors must prioritize Due to missing and poor quality service comprehensive abortion care in crisis- statistics, utilization could not be assessed. affected settings as well as identify and Insecurity and physical obstacles, such as 89 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

poor roads and rain, were significant barriers investments for donors and policy makers, across settings and prevented visits to some merely providing supplies will not result in health facilities. Time pressures, high necessary quality improvements in RH workloads, and coordination challenges service delivery. among assessment team members resulted in Further, the remarkable changes in missing data. Translation error was a health-seeking behavior for pregnancy care possibility, particularly in South Sudan and warrant further exploration. Indeed, the Burkina Faso where the responses had to be identification of effective strategies for translated from a local language to Arabic or increasing demand for and use of skilled French and then to English (in South Sudan). attendants is at the forefront of the The respective assessment teams addressed humanitarian neonatal research agenda [38]. the translation challenges through daily Behavior change to increase use of RH debriefings and group discussions to clarify services is possible and necessary; improved findings. integration of different RH services within facilities would capitalize on already strong Conclusion pregnancy-related health-seeking behavior. Access to RH services, even in the midst of In addition to ensuring systematic war or natural disaster, is a human right that implementation of good quality RH services, saves lives, preserves health, and can enhance humanitarian health actors should—to the physical and mental well-being. Despite the extent possible—meaningfully engage crisis- many obstacles to service delivery, affected communities, especially adolescents, communities affected by crises deserve high in RH programming to augment access to quality RH care. Progress in advancing and this life-saving care. improving the quality of RH in emergencies has been made at the global level in terms of Additional material policies, guidelines, and funding [3,36,37]. While it is promising that many health Additional file 1: Appendix A facilities are providing some RH services, Additional file 2: Appendix B there remains an urgent need to address gaps Additional file 3: Appendix C in implementation—in particular safe Additional file 4: Appendix D abortion services—as well as the quality of Additional file 5: Appendix E care, utilization of RH services, and Additional file 6: Appendix F monitoring and evaluation. Minimum quality Additional file 7: Appendix G standards must be met to meet the health Additional file 8: Appendix H needs of affected populations. Yet, only expanding RH service availability is not sufficient. Gaps in management and knowledge, as well as the biases of some providers continue to impede the provision of RH services in humanitarian settings. Though these may be less quantifiable 90 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

List of abbreviations respective Ministries of Health for their logistical AIDS: Acquired immunodeficiency syndrome; and administrative support. We are also grateful ARV: Antiretroviral; ART: Antiretroviral therapy; to the IAWG sub-working group for their BEmONC: Basic emergency obstetric and collaborative efforts in conceptualizing newborn care; CmONC: Comprehensive and designing the study. Special thanks to emergency obstetric and newborn care; Therese McGinn, Catrin Schulte-Hillen, Basia CMoR: Clinical management of rape; DRC: Tomcyk, and Sathya Doraiswamy for their inputs Democratic Republic of the Congo; EC: as well as Sarah Frank and Sarah Blake for their Emergency contraception; EmONC: Emergency assistance. Finally, we deeply appreciate the obstetric and newborn care; FP: Family planning; time and input of the research participants. This FGD: Focus group discussion; GBV: Gender-based study was funded with generous support of the violence; HIV: Human immunodeficiency virus; US Department of State, Bureau of Population, IAWG: Interagency Working Group on Refugees and Migration and John D. and Reproductive Health in Crises; IDP: Internally Catherine T. MacArthur Foundation. displaced person; IV: Intravenous; IUD: Intra- uterine contraceptive device; MOH: Ministry of Declarations Health; MVA: Manual vacuum aspiration; NGO: This article has been published as part of Conflict Nongovernmental organization; OCP: Oral and Health Volume 9 Supplement 1, 2015: Taking contraceptive pill; PLHIV: People living with HIV; Stock of Reproductive Health in Humanitarian PAC: Post-abortion care; PEP: Post-exposure Settings: 2012-2014 Inter-agency Working Group prophylaxis; PMTCT: Prevention of mother-to- on Reproductive Health in Crises’ Global Review. child transmission; RH: Reproductive health; STI: The full contents of the supplement are available Sexually transmitted infection; UN: United online at http://www.conflictandhealth.com/ Nations; UNHCR: United Nations High supplements/9/S1. Funding for this supplement Commissioner for Refugees; VCT: Voluntary was provided by the MacArthur Foundation. counseling and testing; WHO: World Health Organization. Authors’ details 1Heilbrunn Department of Population and Family Competing interests Health, Mailman School of Public Health, The authors declare that they have no competing Columbia University, 60 Haven Ave, New York, interests. NY 10032 USA. 2University of New South Wales, High St, Authors’ contributions Kensington NSW 2052, Australia. SEC, NC, and MCG led the study 3United Nations High Commissioner for conceptualization and design. SKC Refugees, Rue de Montbrillant 94, 1201 Geneva, conceptualized the paper and was the principle Switzerland. author. SEC provided remote technical assistance during data collection; NC participated in the Published: 2 February 2015 data collection in DRC. SEC and EEW led the quantitative data analysis; SKC conducted the qualitative data analysis. SEC, EEW, NC, and MCG References provided substantial feedback. All authors 1. UNFPA: State of the world population New York; reviewed and approved the final text. 2005. 2. Banatvala N, Zwi AB: Public health and Acknowledgements humanitarian interventions: developing the We gratefully acknowledge the efforts of the evidence base. BMJ 2000, 321:101-5. data collection teams led by Josep Vargas, 3. Austin J, Guy S, Lee-Jones L, McGinn T, Schlecht J: Philippe Cavailler, Mark Beesley, and Monica Reproductive health: a right for refugees and Onyango. We thank International Medical Corps, internally displaced persons. Reprod Health Matter Marie Stopes International, UNFPA, UNHCR, 2008, 16:10-21. the Women’s Refugee Commission, as well as the 91 Casey et al. Conflict and Health 2015, 9(Suppl 1):S3 http://www.conflictandhealth.com/content/9/S1/S3

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Endnotes a The three countries included in the 2004 IAWG evaluation were Republic of Congo, Uganda, and Yemen. b The data pertain to the assessment settings only. Submit your next manuscript to BioMed Central However, for ease of reading, the countries are and take full advantage of: referred to throughout the article. • Convenient online submission c The basic EmONC signal functions include: 1. • Thorough peer review administer parenteral antibiotics; 2. administer • No space constraints or color figure charges uterotonic drugs (e.g., parenteral oxytocin); 3. • Immediate publication on acceptance administer parenteral anticonvulsants for pre- • Inclusion in PubMed, CAS, Scopus and Google Scholar eclampsia and eclampsia (e.g., magnesium sulphate); • Research which is freely available for redistribution 4. perform manual removal of placenta; 5. perform Submit your manuscript at removal of retained products of conception (e.g., www.biomedcentral.com/submit manual vacuum aspiration); 6. perform assisted 93 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

RESEARCH Open Access Reproductive health services for Syrian refugees in Zaatri Camp and Irbid City, Hashemite Kingdom of Jordan: an evaluation of the Minimum Initial Services Package

Abstract Background: The Minimum Initial Services Package (MISP) for reproductive health, a standard of care in humanitarian emergencies, is a coordinated set of priority activities developed to prevent excess morbidity and mortality, particularly among women and girls, which should be implemented at the onset of an emergency. The purpose of the evaluation was to determine the status of MISP implementation for Syrian refugees in Jordan as part of a global evaluation of reproductive health in crises. Methods: In March 2013, applying a formative evaluation approach 11 key informant interviews, 13 health facility assessments, and focus group discussions (14 groups; 159 participants) were conducted in two Syrian refugee sites in Jordan, Zaatri Camp, and Irbid City, respectively. Information was coded, themes were identified, and relationships between data explored. Results: Lead health agencies addressed the MISP by securing funding and supplies and establishing reproductive health focal points, services and coordination mechanisms. However, Irbid City was less likely to be included in coordination activities and health facilities reported challenges in human resource capacity. Access to clinical management of rape survivors was limited, and both women and service provider’s knowledge about availability of these services was low. Activities to reduce the transmission of HIV and to prevent excess maternal and newborn morbidity and mortality were available, although some interventions needed strengthening. Some planning for comprehensive reproductive health services, including health indicator collection, was delayed. Contraceptives were available to meet demand. Syndromic treatment of sexually transmitted infections and antiretrovirals for continuing users were not available. In general refugee women and adolescent girls perceived clinical services negatively and complained about the lack of basic necessities. Conclusion: MISP services and key elements to support implementation were largely in place. Pre-existing Jordanian health infrastructure, prior MISP trainings, dedicated leadership and available funding and supplies facilitated MISP implementation. The lack of a national protocol on clinical management of rape survivors hindered provision of these services, while communities’ lack of information about the health benefits of the services as well as perceived cultural repercussions likely contributed to no recent service uptake from survivors. This information can inform MISP programming in this setting.

*Correspondence: [email protected] 2Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA Full list of author information is available at the end of the article

© 2015 Krause et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/ licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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. 94 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

Background (MISP) for reproductive health has been a Minimum initial services package guideline for care in emergencies since the The need for reproductive health (RH) Inter-agency Working Group (IAWG) on services is a continuing concern in Reproductive Health in Crises’ Reproductive humanitarian settings, response agencies are Health in Refugee Situations: An Inter- increasingly under pressure to document the agency Field Manual (IAFM) was published consequences and outcomes of those in 1996 [2]. The MISP is a coordinated set programs and services they provide to of priority RH services designed for the reduce avoidable morbidity and mortality, onset of an emergency to prevent excess particularly among women and girls. Over morbidity and mortality, particularly among the years, a variety of claims have been made women and girls. The MISP supports by the humanitarian response community building the foundation for comprehensive regarding the direct and indirect benefits of RH services that should be initiated as soon coordinated, high quality RH services, and as the situation stabilizes (see Table 1). The donors are beginning to ask to see the 1996 IAFM and the MISP standard have evidence supporting implementation of undergone revisions in 1999 and 2010. In the those services. The evidence exists but 2010 revision of the IAFM, Additional is often of uneven quality, focusing on Priorities to the MISP were added to the certain aspects of RH service impacts over MISP objectives and priority activities. The others [1]. Additional Priorities to the MISP include The Minimum Initial Service Package ensuring: contraceptives are available to meet

Table 1 MISP Standard

The major objectives and priority activities that comprise the MISP include [2]: ENSURE the health sector/cluster identifies an agency to lead implementation of the MISP. The lead RH organization: • RH Officer in place • Meetings to discuss RH implementation held • RH Officer reports back to health cluster/sector • RH kits and supplies available and used PREVENT AND MANAGE the consequences of sexual violence: • Protection system in place especially for women and girls • Clinical care available for survivors of rape • Community aware of services REDUCE HIV transmission: • Ensure safe blood transfusion practice • Facilitate and enforce respect for standard precautions • Make free condoms available PREVENT excess maternal and newborn morbidity and mortality: • Emergency obstetric and newborn care services available • 24/7 referral system established • Clean delivery kits provided to birth attendants and visibly pregnant women • Community aware of services PLAN for comprehensive RH services, integrated into primary health care (PHC) • Collect existing background data • Identify suitable sites for future service delivery of comprehensive RH services • Coordinate ordering RH equipment and supplies based on estimated and observed consumption • Assess staff capacity to provide comprehensive RH services and plan for training/retraining of staff ADDITIONAL priority activities • Ensure contraceptives are available to meet the demand • Syndromic treatment of sexually transmitted infections (STIs) is available to patients presenting with symptoms • Antiretrovirals (ARVs) are available to continue treatment for people already on ARVs, including for prevention of mother-to-child transmission. • Ensure that culturally appropriate menstrual protection materials are distributed to women and girls. 95 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

the demand; syndromic treatment of sexually the MISP remained largely unknown by transmitted infections (STIs) is available to humanitarian actors for over a decade, patients presenting with symptoms; but increasing awareness was observed in antiretrovirals are available to continue Haiti [8]. treatment for people already on antiretrovirals, including for prevention of Syria crisis mother-to-child transmission; and, that Civil unrest in Syria that started in March culturally appropriate menstrual protection 2011 resulted in four million persons in need materials are distributed to women and girls. of humanitarian assistance at the time of the The MISP is also a standard of care in the assessment, including two million persons Sphere Minimum Standards in Disaster who were internally displaced. In addition, Response and is therefore part of the just over one million refugees had fled the standard of care in humanitarian violence and its aftermath to neighboring emergencies [3]. countries including: The Hashemite To facilitate MISP implementation, the Kingdom of Jordan (Jordan), Lebanon, Iraq, IAWG designed a pre-packaged set of 13 kits Turkey and countries in North Africa [9]. containing drugs and supplies for a three- The social, economic, and health costs of the month period. The United Nations conflict has disproportionately affected Population Fund (UNFPA) leads the women and girls. An estimated 200,000 development, assembly and delivery of the pregnant women, including 22,000 women Inter-agency Reproductive Health Kits who gave birth every month, and of those contents that are noted in the Inter-agency almost 15% were at risk of poor outcomes. Reproductive Health Kits for Crisis There were reports that Caesarean sections Situations[2]. Previous MISP assessments within Syria had increased from 19% to 45% were conducted in Pakistan (2003), Chad between 2011 and 2013, respectively [10]. (2004), Indonesia (2005), Kenya (2007) and Incidents of gender-based violence, such as Haiti (2010) [4-8]. Over the years findings sexual harassment and rape, had been showed gaps in implementation; poor overall reported [11]. coordination including a lack of standard protocols and procedures, lack of donor Syrian refugees in Jordan support, inadequate knowledge of MISP There were an estimated 355,493 Syrian priorities and activities, poor quality and/or refugees living in Jordan with 298,025 availability of referral services, and registered by the United Nations High inadequate monitoring of service delivery. Commissioner for Refugees (UNHCR) and Assessments also revealed variations with 57,468 awaiting registration at the time of the regard to the availability of trained staff and assessment. An overwhelming majority of supplies needed to prevent excess the unregistered refugees were residing in maternal/neonatal morbidity and mortality, urban areas. The majority (55.2%) of and sexual violence and human registered refugees were residing in Zaatri immunodeficiency virus (HIV) prevention camp, with an additional 133,660 refugees activities [4-8]. Lastly, findings showed that residing in urnab areas including 47,087 96 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

(15.2%) and 39,339 (13.2%) residing in Irbid were in place for Syrian refugees living in and Amman governates, respectively. The Irbid City and Zaatri Camp as an example to largest refugee camp Zaatri hosted 164,365 highlight factors that both support and refugees [12]. As relief agencies ensured that hinder the availability and use of MISP the specific needs of women and girls were services, and to make recommendations factored into humanitarian health response, towards improved response and scaling-up they relied on the Jordanian Ministry of of services [17]. Health’s (MOH) established guidelines on maternal, newborn care and post abortion Methods care; HIV prevention and treatment; and Site selection family planning [13]. Abortion in Jordan is At the time of the evaluation Zaatri Camp legally permitted to preserve a woman’s had a refugee population of 164,365 and physical and mental health or because of Irbid City 47,087, respectively. Irbid City was fetal impairment [14]. Regarding HIV, Jordan included as an urban non-camp refugee site. is characterized by a lowprevalence epidemic. Of note is that Jordanian law states that Study design foreigners staying in Jordan beyond three This was a formative evaluation using three months who are HIV positive can be methods; (1) key informant interviews deported [15]. The reproductive health (KIIs), (2) health facility assessment (HFAs), indicators prior to the crisis in Syria are and (3) focus group discussions (FGDs). It important to note for agencies in Jordan was conducted from March 17-22, 2013. The implementing the MISP. For example, Syria global evaluation team was supported by also has low HIV prevalence. A skilled seven local study staff. medical staff attends 96% of pregnant women during their births and the Cesarean Domains of evaluation section rate was 26%. Abortion in Syria is In order to assess the main variables of legally permitted only to save a woman’s life. interest we examined the domains listed The contraceptive prevalence rate is 54%. below: Maternal and neonatal mortality rates are 65 • MISP awareness and knowledge including deaths per 100,000 live births and 8 deaths activities related to MISP response, per 1000 live births, respectively [16]. training of responders in the MISP, awareness of funding allocation for RH Purpose of the evaluation including MISP kits, and knowledge of the This study, one of the six components of the five MISP objectives. 2012-2014 IAWG global evaluation of RH • Coordination of the MISP including in humanitarian settings, a decade follow-up whether regular coordination meetings are to the 2002-2004 IAWG global evaluation, held with all relevant stakeholders and how aimed to determine to which extent the effective coordination meetings were in MISP was established in an emergency facilitating MISP coverage. setting. The purpose of this evaluation was • Prevent and manage the consequences of to examine to what degree MISP services sexual violence comprising safe access to 97 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

and use of health facilities and the these initiatives were undertaken and the availability of clinical care for survivors of extent that the MISP was integrated. sexual violence. • Reduce HIV transmission including Sampling ensuring safe blood transfusion; facilitating Sampling procedures for KIIs involved a and enforcing the implementation of purposeful selection based on a February standard precautions at health facilities to 2013 mapping of health partners (n=36). prevent the spread of infections; and , Sampling of health facilities included making free condoms available. obtaining a list of health facilities that • Prevent excess maternal and neonatal provided RH services in Zaatri Camp (n=15) morbidity and mortality including the and Irbid City (n=6). Participants in FGDs availability of emergency obstetric and were recruited by partner agencies that new born care services and an emergency selected a purposive sample of female youth referral system 24 hours per day 7 days per (18-24 years of age) and older women (aged week; the distribution of clean delivery 25-49 years). In Zaatri Camp, the groups kits; and, community awareness of existing included those that lived near and farther services. away from health facilities, and newly arrived • Plan for comprehensive RH services, refugees (arrival within the past two months). integrated into primary health care In Irbid City, the groups were allocated based including the collection of existing on refugee registration status. background data; identification of suitable sites for future service delivery of Data collection procedures and analysis comprehensive RH services; coordination The KIIs questionnaire was modified from on ordering RH equipment and supplies one used in past MISP studies [6-8] to based on estimated and observed integrate the emerging importance of consumption; and, assessing staff capacity disaster risk reduction and emergency to provide comprehensive RH services preparedness initiatives and to quantify and planning for training of staff. awareness and knowledge of MISP • Additional priorities to MISP comprising objectives, activities and the availability of the availability of contraceptives to meet services. Three pilot-tests of the KII tool demand; syndromic treatment of sexually were undertaken. Invitations to participate in transmitted infections (STIs) to patients a KII were sent via email to the partners. A presenting with symptoms; antiretroviral member of the study team obtained written medicines to continue treatment for consent, conducted the interviews in English people already on antiretrovirals including with, managers, physicians and nurses and for prevention of mother to child recorded handwritten notes during the transmission; and, culturally appropriate interview. menstrual protection materials for women Selected health facilities were visited and girls. beforehand by members of the study team • Assessment of disaster risk reduction and to review the HFA evaluation procedure. emergency preparedness to determine if One relevant staff assisted the assessment 98 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

teams and oral consent was obtained. The translated while in the field. The team coded HFA consisted of semi-structured interviews text into broad themes and sub-topics, and with physicians, managers and nurses discerned patterns emerging from the conducted in English and use of a information. A question-by-question standardized check list of equipment and approach was used to summarize participant supplies [18]. comments into multiple themes. During the The FGD tool was modified from a tool coding process, data were continuously used in prior MISP evaluations to reviewed, emerging patterns noted and accommodate cultural and age appropriate relationships between constructs and themes issues among Syrian refugees. The tool was identified. Data were compared across sites, translated into Arabic and back-translated to age groups and registration status. The two English. The FGD tool was piloted in Zaatri study team members who coded the FGD Camp with two groups of female youth and information met routinely to review the two groups of older women. FGDs were themes and gain consensus on interpretation held in private rooms within health clinics in of the results. the camp and in private rooms hosted by local organizations in Irbid City. Verbal Ethical review informed consent was obtained from all The evaluation protocol was reviewed and participants. cleared by the Centers for Disease Control Data were reviewed across questions and and Prevention (CDC), UNFPA and United study sections to discern themes and patterns Nations High Commissioner for Refugees in the information collected in the KIIs. The (UNHCR) Jordan. KIIs interview data were compared across the data from the FGDs to examine Results similarities and differences. Data from the Respondents and health facilities HFAs were entered into tables and presented The study team conducted 11 KIIs with as simple numeric data providing descriptive agency staff. Five of 15 health facilities run analysis and results; as the number of by national and international organizations facilities visited in each setting (Zaatri camp, and militaries were visited in Zaatri Camp. Irbid city and Mafraq hospital) were too Study sites included three health clinics, one small to use percentages. Quantitative data camp hospital, one maternity hospital and entry from the HFA was also done in an the MOH Mafraq referral hospital located Excel spreadsheet. Following the completion outside of Zaatri camp in Mafraq. Six health of the FGDs, the study team member facilities were visited in Irbid City, two health reviewed each question with the facilitator centers, two clinics, and two hospitals. The and note takers. At the end of each day, a team conducted 14 FGDs among refugee debriefing was held with all FGD team women, in Zaatri Camp there were 101 members to assess any methodological women and in Irbid City there were 58 issues, such as translation congruence or women, respectively. questions that were not understood by participants. Notes from the FGDs were 99 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

MISP awareness and knowledge concern that the distribution of clean All but one of eleven key informants (KIs) delivery kits could encourage home was aware of the MISP, and nearly half deliveries. knew all five MISP objectives. However, All facilities in Zaatri Camp were open approximately two-thirds of KIs were not and convenient for adolescent females, but aware of the additional priorities of the none of the facilities had an appropriate MISP. entrance for clients with disabilities. None of the five facilities visited provided RH Coordination of the MISP outreach services. In the FGDs, the majority Nine KIs reported that UNFPA hosted RH of women in the Zaatri groups agreed that coordination meetings weekly in Zaatri agencies had not communicated directly with Camp and monthly in Amman. Participants the refugees about the emergency response. reported that coordination mechanisms, Across the groups in Irbid City, most women health indicator collection issues (although reported that they were not contacted by there was greater emphasis on Zaatri Camp agencies and learned about services through indicators) and MISP implementation was their community. discussed. A KI also said that non- governmental organizations that are not Prevent and manage the consequences funded are missing from coordination of sexual violence meetings. In addition, several respondents Seven key informants reported knowledge said that RH coordination for urban areas about measures to prevent sexual violence was lagging behind camp coordination and treat survivors. However, measures to because the coordination meetings in prevent sexual violence were insufficient and Amman tended to focus on the more visible only one site had the human resource daily refugee influx and refugees capacity and supplies to provide clinical care concentrated in the camp setting in Zaatri for rape survivors. whereas refugees in urban areas, disbursed In Zaatri Camp, women expressed within host communities were less visible. concerns about the lack of lighting and their The majority of KIs reported that MOH fears of using the toilets at night. In Irbid and/or World Health Organization City, women reported feeling unsafe sending protocols were available to support MISP their daughters to school on public buses. implementation and funds were available for Women said that they were fearful of telling a MISP response. Three quarters of their families of sexual violence due to fears respondents reported that RH Medical Kits of honor killing, or being disowned by were available and adequate for this response. family. The women discussed what they In both settings, all groups reported that perceived as more cases of domestic clean home delivery kits were not distributed. violence in the camp than what they One KI explained that given facility-based observed while living in Syria but were deliveries were available in Zaatri camp and fearful of negative consequences if they the urban setting, and the norm among the reported experiencing violence. The women populations in Jordan and Syria, there was a voiced a desire mostly for psychosocial 100 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

services, in addition to prevention and in both Zaatri Camp and in Irbid City from medical care but were unaware of service a blood bank. Most facilities enforced availability. Nearly all women across the standard precautions, including use of groups in Irbid City agreed that they would disposable needles and syringes and sharps not feel comfortable attending health disposal boxes. In an event of a health services for reasons including no benefits worker’s occupational exposure to HIV, from receiving health care and family limited occupational post-exposure stigmatization. Additionally, all groups with treatment was available in Amman. young women said that they would not tell Eight of ten key informants reported anyone if they experienced violence. that condoms were available through clinics Regarding incidents of sexual violence that and in women’s safe places. In Zaatri Camp, are usually reported to UNHCR protection, male condoms were in stock, but female the Moroccan Field Hospital had not condoms were unavailable. In Irbid City received any sexual violence survivors, health facilities, most clinics did not supply although Mafraq Hospital had received one. condoms to non-married women. Men could Treatment and forensic evidence collection buy condoms from pharmacies. FGD was available at Prince Hamza or Mafraq participants showed very limited knowledge hospitals but they did not have standard of where they could obtain condoms in protocols. Jordan Health Aid Society (JHAS) Zaatri Camp but participants in Irbid City clinic was the only facility visited that has a understood that condoms were available protocol to manage sexual violence survivors through pharmacies. in the camp. In Irbid City, there was a formal referral protocol for sexual violence Prevent excess maternal and newborn survivors from the health centers to the morbidity and mortality Family Protection Unit including a standard Approximately half of the key informants incident reporting form. Partners stated the could identify all of the priority activities MOH was developing a national protocol for within the objective to prevent maternal and clinical management of rape survivors. newborn morbidity and mortality. In Zaatri Camp, normal deliveries, basic emergency Reduce HIV transmission obstetric care and newborn care functions Three of nine key informants had essential were conducted at the Gynécologie Sans knowledge on how to reduce HIV Frontières maternity clinic. Obstetric transmission. When asked about HIV emergencies requiring comprehensive transmission, all FGDs from Zaatri Camp emergency obstetric care including post- and five groups in Irbid City stated that they abortion care and management of newborn knew about HIV and acquired complications were referred to the Moroccan immunodeficiency syndrome (AIDS). Also, Field Hospital. A few women in Zaatri Camp refugee women did not trust the blood described deterioration in the quality of supply and had a greater fear of contracting services over time, including a lack of HIV through blood than sexual contact. physical examinations and drugs and Safe blood was available for transfusion unqualified health providers. The 101 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

deterioration in services may be linked to the through health education campaigns. In large influx of refugees that had been Zaatri Camp, most reproductive health experienced in the months prior to and indicators were collected, but the quality of during the evaluation. the indicators was questioned. For example, At two Irbid City referral hospitals one report showed a hospital occupancy rate services for normal deliveries, basic and of 120%. Facilities in Irbid City separately comprehensive emergency obstetric care, reported refugee and non-refugee indicators comprehensive abortion care within the law, to the MOH. In terms of planning future and post-abortion care were available. FGD sites for delivery of services, UNFPA had participants stated that a UN registration recently opened a new maternal and child card resulted in free services for pregnant health center in Zaatri Camp, while planning women. Despite free services, women was also underway to establish more showed reluctance to use them as they were obstetric services for normal deliveries at perceived to be “bad” quality due to the lack Primary Health Clinics, at one per 5,000 of privacy and female providers. persons. UNHCR pays health care costs for A referral system to facilitate transport refugees referred to Mafraq hospital from and communication from the community to Zaatri Camp. In Irbid City health facilities, health facilities was available in the camp and registered refugees did not have to pay for in Irbid City, with ambulance transportation clinical services as they are covered by the the most common mode of transport in MOH. In most government clinics, both settings. Due to traffic congestion, unregistered refugees, unless they were referrals could take 30 minutes or more in referred by JHAS and UNHCR covered the the camp, while referrals in Irbid City took cost, paid similar fees to uninsured 10-45 minutes. In all of the health facilities Jordanians. in Zaatri Camp and Mafraq Hospital, In the camp, there were many complaints qualified medical personnel were present 24 from FGDs about lack of medications, while hours a day, seven days a week but staff in Irbid City, complaints focused on the cost complained about an increased case load and of medications. In Zaatri Camp, requests insufficient human resources since the onset were made to increase services for special of the crisis. needs populations and vulnerable community members. In Irbid City, the main Plan to integrate comprehensive RH reasons for not seeking health care among services into primary health care refugees were the disrespect shown to the Just over half of the key informants were women by providers, limited or inappropriate aware of activities to plan for comprehensive medicine and long wait times for care. One RH services such as assessing and addressing KI said that inter-agency service guides on staff capacity to provide comprehensive RH health and protection services had been services. Seven of eight respondents developed for Syrian refugee-impacted reported informing the community of the governorates of Jordan. A KII reported that health benefits to seeking RH services. The information and education was provided to majority stated that this was undertaken new arrivals through service booklets, given 102 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

to JHAS who subsequently distributed them protocols for syndomic management of to refugees, including unregistered refugees. STIs. None of the facilities at Zaatri Camp In addition, a UNHCR help desk was provided antiretroviral therapy, including the available. referral hospital in Mafraq. Those needing antiretroviral therapy were referred to Additional priorities of the MISP facilities in Amman. It was reported in the An array of family planning methods, FGDs that women in Zaatri Camp received including oral contraceptive pills, injectable a single distribution of hygiene products contraceptives, and intrauterine devices were upon their arrival but staff at the distribution available. According to Jordanian guidelines sites were rude to them. Half of the women emergency contraception can be provided had heard about distributions at registration through combined oral contraceptives but, when they returned for additional although a dedicated emergency hygiene supplies, they were told that none contraception product was only available for were available. post rape care in one setting. There were provider barriers in access to family planning Integration of reproductive health into including emergency contraception. For disaster risk reduction and emergency example, one provider stocked preparedness contraceptives but reported that “women did Just over half of KIs reported that there was not want them” while another provider a national disaster risk reduction agency in reported they would not give emergency Jordan. Mixed responses were received in contraception to a rape survivor or an terms of whether a health risk assessment unmarried woman. There were cost barriers had been undertaken and whether disaster in the urban context. Although focus group risk reduction health policies or strategies participants expressed a strong need for were in place. family planning, half of the participants in In terms Zof agency preparedness, Zaatri Camp and almost all in Irbid City were approximately twothirds of respondents unaware of the locations for free family reported that their organization undertook planning services. Most women in Zaatri preparedness for this crisis. Preparedness Camp and Irbid City mentioned that they trainings included a national training on the would try to self-abort through lifting heavy MISP in June 2011; the MISP regional objects if they had an unwanted pregnancy. training of trainers in Cairo in December Both providers and service users indicated 2012; MISP training in Zaatri Camp; and uneven and inadequate availability of gender-based violence training for police. services and supplies related to STIs and Regarding the prepositioning of supplies, HIV, as well as menstrual hygiene. Syndromic while four out of nine KIs reported that RH management of STIs was not mentioned by supplies were procured and pre-positioned, representatives of the facilities visited in a representative from the agency responsible Zaatri Camp. Most providers said that STI for this process said that supplies were not cases were rarely seen. In Irbid City settings pre-positioned. providers were not familiar with standard In summary facilitating factors to MISP 103 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

implementation are Jordan’s pre-existing camp and had limited attention on Amman health care infrastructure and willingness to or other cities, despite the larger number of address RH among Syrian refugees. Other refugees in the urban areas. As compared to factors included: the identification of a previous MISP assessments, this MISP dedicated agency within the health sector to assessment shows attention by donors and lead RH coordination; available funding for humanitarian actors to address reproductive RH; relative concentration of people in health in emergencies as reflected in the Zaatri Camp; prior MISP training; and, leadership by the MOH, UNHCR and highly skilled and dedicated work force. In UNFPA as well as donor funding for RH and contrast, reported barriers to MISP largely sufficient supplies. implementation included insufficient funding for the urban response; a lack of female staff; Prevention and response to sexual and the absence of a national protocol on violence clinical management of rape. Other There appeared to be a lack of priority in the perceived barriers included: limited supplies humanitarian response on measures to distribution despite availability; the crisis prevent sexual violence in addition to the occurring before Jordan implemented its challenges to establishing clinical care for MISP contingency plan; and the large urban rape survivors where the later could be caseload. related to the lack of a national clinical management of rape survivor protocol with Discussion challenges around the use of emergency MISP coordination contraception and post-exposure The importance of coordination in prophylaxis. The infrequency of survivors humanitarian crisis has been articulated in reporting for treatment is possibly related to: global initiatives such as the Interagency Syrian women’s lack of knowledge about the Standing Committees humanitarian reform benefits and availability of health care; process [19]. The IAWG advocates taboos around talking about sexual violence coordination of RH interventions within the in the community; and an inadequate number broader humanitarian response to be situated of trained providers/service delivery points. within the health sector. Jordan’s status as an Women are unlikely to weigh the benefits of upper middle income country [20], and the seeking services against their fears of regional support it received from other retribution and cannot make an informed countries to address the Syrian crisis created choice about seeking care without knowledge a solid foundation for the improved MISP on how medical care can prevent health policy environment. Appointing a RH lead consequences. early in an emergency indicates strong commitment to the issue by the MOH. In HIV prevention comparing urban to camp implementation In terms of HIV prevention, priority of MISP, the key difference was that activities were mostly in place, likely due to coordination meetings held in Amman, an the existing Jordanian HIV policy and urban area, were reported to focus on Zaatri accessible and stocked blood banks. Cultural 104 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

sensitivities may have inhibited providers services [22]. This form of outreach is from making free condoms visible and important particularly in an emerging crisis readily attainable. setting if prevailing attitudes of the population are negative towards the health Prevention of maternal and newborn care system. Another issue that affects morbidity and mortality service uptake is stock-out of RH supplies. In order to prevent maternal and newborn In both Irbid City and Zaatri Camp delays morbidity and mortality resulting from and gaps persisted in expanding some obstetric complications, skilled birth comprehensive RH services. In light of the attendants, emergency obstetric care and ongoing influx of refugees, access to health newborn resuscitation should be available resources will need to be monitored and and of high quality [21]. These MISP maintained despite the changing activities were largely in place and facilitated humanitarian situation. Previous MISP by existing MOH standards, systems and assessments conducted in Haiti (2011) and structures for health facility deliveries. In the Indonesia (2005) presented similar gaps in urban context, the MOH had the benefit of service delivery areas such as care for the experience from addressing the needs of survivors of sexual violence, in particular, the Iraqi refugee population. Despite the informing communities about the benefits availability of services however, many and location of services as well as treatment women were displeased with the quality of for rape [8,6]. care that was perceivably impacted by the ongoing surge in refugee influx and the Planning for comprehensive subsequent demands on service providers, as reproductive health services well as the limited number of primary health Good collection of RH indicators for clinics in Zaatri Camp. A key difference monitoring of services brings together between camp and non-camp based refugees relevant partners to ensure that users of was the use of UNHCR registration card to health information have access to reliable, receive health services outside of the camp, authoritative, useable, understandable and which was repeatedly expressed as a barrier comparative information [23]. While the to seeking RH care among refugees. Access camp and urban contexts are by nature to high quality RH services is known to different context, the MOH, UNHCR and improve health outcomes. UNFPA were all responsible for health including reproductive health. However, in Information, education and the urban context, health services were communication about the benefits of largely the responsibility of the MOH with seeking care and location of services support from local non-governmental Strategies are needed in order to improve organizations whereas services provided in acceptance of services and uptake of Zaatri camp included external organizations positive health behaviors. Communication of and non-traditional organizations such as the health information is essential to improve military. A quality health information system people’s knowledge and acceptance of health takes resources, but it is worth the effort to 105 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

address obstacles, including poor quality, dignity. They may have fear due to increased limited flow, and lack of standardized risk of sexual abuse and exploitation as they indicators across agencies. These challenges seek ways to obtain materials. can be addressed through applying basic surveillance principles and training of staff Comparison to previous MISP [24]. assessments This MISP assessment showed key Additional priorities of the MISP informants had more awareness and The four additional priorities to the MISP knowledge about the specific objectives and were not very well known by key informants activities of the MISP as a standard of care and partially established. The lack of in humanitarian emergencies than previous knowledge about the additional priorities to MISP assessments building on the growing the MISP may be due to the fact that they are awareness noted in the Haiti MISP relatively new guidelines as they were first put assessment in 2010 [8]. The greater forth in the revised for field testing version awareness may be the result of UNFPA and of the IAFM in 2010. This evaluation found Sexual and Reproductive Health Programme that some of these services were in place, in Crisis and Post-crisis Situations (SPRINT) while others were not. For example, national and regional training’s on the MISP contraceptives were available in both sites, for Ministry of Health and NGOs over the although primarily for married women. past several years. Maternal and newborn Awareness of locations where contraceptives services were largely in place unlike MISP could be obtained was limited. Health care assessments in Haiti and Pakistan [8,4]. This provider biases limited the availability of is likely due to the pre- existing level of emergency contraception for Syrian refugees: maternal and newborn care in Jordan until a dedicated product is available, available to urban refugee populations and providers and refugees can benefit from national and regional partners support of information and education around the use of health facilities offering advanced maternal oral contraceptive pills as emergency and newborn care in Zaatri camp. Similarly, contraception for unprotected intercourse in this more developed context the and after rape. availability of safe blood for transfusion and Syndromic treatment of STIs was not the practice of standard precautions is a available, likely due in part to the absence of standardpart of practice pre-crisis while the a national protocol on treatment of STIs or distribution of condoms is a culturally lack of health seeking for symptoms. In this sensitive issue. However, gaps in prevention setting the prevalence of HIV is low but of sexual violence and clinical care for although there was little demand for survivors of sexual violence are consistent antiretrovirals there may be a time where this with previous MISP assessments. This could may change and drugswill need to be be due to provider’s ongoing lack of procured. Lastly, the lack of hygiene, commitment to preventing sexual violence including for menstruation, was upsetting to and the lack of national protocols for clinical women and challenging to their sense of care for survivors of sexual violence. In 106 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

addition, while key informants in previous and use of the MISP. The overall availability MISP assessments reported gaps in funding of MISP services for Syrian refugees in and supplies as barriers to MISP Jordan are consistent with other studies in implementation [4-8], there were very limited the IAWG global evaluation showing to no reports of gaps in funding and supplies growing awareness and commitment to the to support MISP implementation in Jordan. MISP [26,27]. The authors hope that the This could be due to overall funding levels upward trend to implement the MISP for the Syrian refugee crises and the continues in new emergencies, with a focus commitment of MOH, UNFPA and on enhancing quality of care and an efficient UNHCR to ensure the MISP was integrated and smooth transition to comprehensive in the health sector response [25]. reproductive health services. Still, as is often the case, considerable uncertainty attends any Limitations major humanitarian response. Therefore, an There were several limitations to this important strategy to enhance MISP evaluation conducted in an ongoing and implementation is to remain focused on the rapidly evolving emergency that resulted in a tangible public health lifesaving interventions large influx of refugees each day. Time and that women and girls so desperately need in security constraints limited information crises. gathering, especially in the camp. Time constraints for the HFA resulted in the interviewers changing some of the questions List of abbreviations and their order to maximize responses from AIDS: Acquired immunodeficiency syndrome; CDC: Centers for Disease Control and Prevention; busy informants. For example, the team FGD: Focus group discussion; HFA: Health facility simply noted that surgery packs for Cesarean assessment; HIV: Human Immunodeficiency Virus; sections were available, rather than providing IAWG: Inter-agency Working Group on an accurate inventory of all individual items Reproductive Health in Crises; JHAS: Jordanian of equipment and supplies. Regarding Health Aid Society; KII: Key informant interviews; MISP: Minimum initial service package; MOH: FGDs, limited time also impacted the team’s Ministry of Health; RH: Reproductive Health; STI: ability to probe, which constrained in-depth Sexually transmitted infection; UNFPA: United understanding of some issues. Translation Nations Population Fund; UNHCR: United Nations error may also be present, which was High Commissioner for Refugees; WRC: Women’s Refugee Commission. countered through daily debriefings with the field team to confirm meanings of words Competing interests and phrases, and ensure maximum The authors declare that they have no competing transcription. interests.

Authors’ contributions Conclusion BT developed the study protocol and process While significant progress has been made in evaluation methodology with input from SK and MO. BT, HW, SS, MO, WD revised the study tools; MISP policy and guidelines at the global SK, HW, SS, MO, WD implemented the study in level, and awareness has grown at the field Jordan; SK and BT led the drafting of the article; level, gaps exist in the systematic availability SK, BT, HW, SS, MO, WD were co-contributors, 107 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

with NG and ES contributing to the literature health during emergencies: Time for a new review. All authors reviewed and approved the paradigm? Global Public Health 2013, :342-356. final text. 2. United Nations High Commissioner for Refugees: Inter-agency Field Manual on Reproductive Health Acknowledgements in Refugee Settings. Geneva; 1996. The IAWG MISP study team is grateful to the 3. The Sphere Project: Humanitarian Charter and UNHCR, UNFPA and the International Rescue Minimum Standards in Disaster Response. Geneva; Committee and in particular Drs. Ann Burton, 2004. Shible Sahbani and Ana Calvo, Heather Lorenzen, Robert Warwick and Firas Dabbas 4. Women’s Refugee Commission: Still in Need: Reproductive Health Care for Afghan Refugees in for agreeing to host this mission recognizing the Pakistan. 2003. importance of RH even at the height of demands to their time on the ground. We would also like 5. Women’s Refugee Commission: Life Saving to thank the interpreters and note takers Dia Al Reproductive Health Care in Chad: Ignored and Hayek, Rosanna Petro, Mai Hussein, Ahmad Neglected. 2004. Ababneh, Ibtisam Darwish, Amal Rizqallah and 6. Women’s Refugee Commission: Reproductive Tariq Saleh. We would also like to thank Mihoko Health in an Emergency: Assessment of the Tanabe and Diana Quick of the WRC for editing Minimum Initial Service Package in Tsunami- the article. Finally, we very much appreciate affected Areas in Indonesia. 2005. agency representatives working on the ground in 7. Women’s Refugee Commission: Reproductive Syria and Syrian women themselves for taking Health Coordination Gap, Services Ad Hoc: the time to meet with us. Minimum Initial Service Package (MISP) in Kenya. 2008. Declarations 8. CARE, International Planned Parenthood This article has been published as part of Conflict Foundation (IPPF), Save the Children, Women’s and Health Volume 9 Supplement 1, 2015: Taking Refugee Commission: Priority Reproductive Health Stock of Reproductive Health in Humanitarian Activities in Haiti: An Inter-agency MISP Settings: 2012-2014 Inter-agency Working Group Assessment. 2011. on Reproductive Health in Crises’ Global Review. The full contents of the supplement are available 9. United Nations Office for the Coordination of Humanitarian Affairs: Syrian Humanitarian Bulletin online at http://www.conflictandhealth.com/ Issue 21. [http://reliefweb.int/sites/reliefweb.int/files/ supplements/9/S1. Funding for this supplement resources/Syria%20Humanitarian%20Bulletin%20 was provided by the MacArthur Foundation. No%2021.pdf].

Authors’ details 10. United Nations Population Fund: An estimated 1Women’s Refugee Commission, 122 East 42nd 200,000 pregnant women in Syria in need of Street, New York, New York 10168, USA. urgent care. [http://www.unfpa.org/public/ 2Centers for Disease Control and Prevention, home/news/pid/16793]. 1600 Clifton Road, Atlanta, GA 30333, USA. 11. International Federation for Human Rights: Violence 3Boston University School of Public Health, 801 against Women in Syria: Breaking the Silence: Massachusetts Avenue, Boston, MA 02118, USA. Briefing Paper Based on an FIDH assessment 4United Nations Population Fund, 605 3rd Ave, mission in Jordan in December 2012. 2013 New York, NY 10158, USA. [http://fidh.org/IMG/pdf/syria_sexual_violence- web.pdf]. Published: 2 February 2015 12. United Nations Weekly Inter-agency Situational Report JORDAN, Syrian Refugee Response Update: March 10-17, 2013. [http://reliefweb.int/report/ References jordan/un-weekly-inter-agency-situational-report- 1. Onyango MA, Hixson BL, McNally S: Minimum jordan-syrian-refugeeresponse-update-10-17]. Initial Services Package (MISP) for reproductive 13. The Hashemite Kingdom of Jordan Ministry of

108 Krause et al. Conflict and Health 2015, 9(Suppl 1):S4 http://www.conflictandhealth.com/content/9/S1/S4

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Douglas N, Buehler JW, Berkelman RL, The Submit your manuscript at www.biomedcentral.com/submit 109 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

RESEARCH Open Access Retrospective analysis of reproductive health indicators in the United Nations High Commissioner for Refugees post-emergency camps 2007–2013

Abstract Background: The United Nations Refugee Agency’s Health Information System issues analytical reports on the current camp conditions and trends for priority reproductive health issues. The goal was to assess the status of reproductive health by analyzing seven indicators and comparing them to standards and host country estimates. Methods: Data on seven indicators were extracted from the database during a seven-year period (2007 through 2013). A standardized country inclusion criterion was created based on the year of country implementation and the percentage of missing reports per camp and year. The unit of analysis was monthly camp reports by year within a country. To account for the lack of independence of monthly camp reports, the variance was computed using Taylor Series Linearization methods in SAS. Results: Ten of the 23 eligible countries met the inclusion criterion. The mean camp maternal and neonatal mortality rates, except for two country years, were lower than the host country estimates for all countries and years. There was a significant increase in the percent of births attended by a skilled birth attendant (p < 0.0001), and 8 of 10 countries did not meet the standard of 100 % for all reporting years. The percent of births performed by Caesarian section (p < 0.001), were below the recommended minimum standard for nearly half of the countries every year. There was a significant increase in the percent of women screened for syphilis across years (p < 0.0001) and the percent of women who received post HIV exposure prophylaxis (p < 0.0001) and 10 % reached the standard for all reporting years, respectively. Conclusion: Comprehensive, consistent and comparable statistics on reproductive health provides an opportunity to assess progress towards indicator standards. Despite some improvements over time, this analysis confirms that most countries did not meet standards and that there were differences in reproductive health indicators between countries and across years. Consequently, the HIS periodic monitoring of key reproductive health indicators at the camp level should continue. Data should be used to improve intervention strategies. Keywords: Reproductive health, Refugees, Health information system, Health indicators

*Correspondence: [email protected] See related supplement at http://conflictandhealth.biomedcentral.com/articles/supplements/volume-9-supplement-1 2Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Con- trol and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA Full list of author information is available at the end of the article

© 2016 Whitmill et al. 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 110 Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

Background improvements in mother-to-child- Reproductive health (RH) indicators are used transmission programs and family planning by the United Nations High Commissioner commodities. In contrast, disparities in for Refugees (UNHCR) and its health emergency obstetric care and newborn care partners to ensure resources are correctly services remained unchanged [7] and clinical targeted to those who need them, respond components of the Minimum Initial Service quickly to public health problems, monitor Package (MISP) were lacking in three settings trends, and evaluate the effectiveness of well beyond the emergency phase [8]. Post- interventions and service coverage [1]. The abortion care is still behind compared to RH indicators collected are essential to other RH interventions due to lack of describe the burden of RH among refugee funding and systematic evaluations. In women of reproductive age. The global addition GBV programs showed a lack of distribution of RH indicators can show prevention efforts against sexual violence differences in prevalence between countries and staff trained in the clinical management or regions that will help inform policy or of rape. Other problem areas found were the advocacy but may have very little impact on inconsistent availability of antiretroviral for camp and refugee specific lifesaving HIV and the lack of prevention, testing and interventions. Without timely, and accurate treatment of other sexually transmitted data refugee women could be at increased infections (STIs). Lastly, an assessment of risk of mortality and morbidity. In general family planning programs showed a gap in more emphasis needs to be placed on the funding and commodities such as tools and resources that are needed to collect intrauterine devices (IUDs), permanent data to ensure the indicators are of high methods and emergency contraception [9]. quality [2]. As humanitarian actors gain experience to In January 2013, there were 15.4 million solve RH issues, this information will be refugees worldwide–approximately 48 % of useful to improve services to populations these refugees were women and girls [3, 4]. affected by a crisis. As shown in a recent global evaluation of Since 2006, UNHCR and its health reproductive health (RH) in humanitarian partners have been using a unified health settings from 2012 to 2014, refugee women information system (HIS) to monitor refugee and children are the most vulnerable to the public health and HIV programs in camps consequences of displacement [5]. A positive and urban settings. At the start of 2010, HIS finding in the study showed the number of provided services to 1.5 million refugees health proposals with an RH component operating in 18 countries, 85 refugee camps, increased by an average of 10 % per year and through 24 different partners [10]. Past from 2002 to 2013 [6]. Other positive published studies have used the HIS data to findings showed significant progress in evaluate camp nutrition programs, the maternal and newborn health as evidenced utilization of outpatient services, the burden by an increase in funding and program of malaria, and under five morbidity and evaluations, an increase in funding of mortality [11-14]. Important contributions gender-based violence (GBV) programs, of these papers included recommendations 111 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

to modify nutritional indicators, and the the data analysis and determined the study accuracy of population indictor estimates was surveillance activity and not human (number of women of reproductive age and subject research. All analysis was done using children under five). In addition, there were SAS software, Version 9.3 of the SAS policy and advocacy issues identified such as Institute, Inc.© (Cary, NC) [15]. the need to support equitable and higher quality malaria eradication programs in Country and camp inclusion refugee and host populations. Lastly, through criteria these studies awareness was turned towards Using HIS data taken from operating refugee the importance of the HIS unified systems camp health facilities from 2006 to 2013, we utility to analyze and disseminate health reviewed HIS data from a total of 23 information. countries. A country was included in the To monitor RH services in camps, the analysis if it had at least one acceptable camp HIS uses RH indicators to measure and with monthly reporting data from no later determine progress in achieving the than 2008 and had no more than two UNHCR predetermined standards. This unacceptable camps. A camp was considered study was part of the Interagency Working acceptable for inclusion into the analysis if it Group in Reproductive Health Global met the following two criteria: Evaluation of RH in humanitarian settings. 1. Completeness: A camp had completed 90 The purpose of this study was to conduct a % of its monthly reports per year (<=10 retrospective review of selected HIS RH % missing monthly reports). indicators of refugees by country to examine 2. Total Reporting Months: A camp had at trends over time and assess if the indicators least 6 months of reporting data. Camps meet the UNHCR standards. that did not meet the inclusion criteria were not included in the analysis. Data Methods analysis started in 2007 or 2008, This analysis used data from RH indicators depending on the availability of the obtained from UNHCR’s HIS Microsoft monthly reports. Access™ (Redmond, WA) database over a seven-year period (2007 through 2013). Data RH indicator inclusion criteria selected for this analysis were abstracted Fifty-seven RH indicators are included in the from the HIS Access database by the HIS HIS system. For this analysis, seven supervisor at UNHCR headquarters in indicators were chosen after screening the Geneva and converted into Excel RH indicators for usability, plausibility, and spreadsheets. The variables included relevancy of the reported indicator data. continent, name of country, name of camp, Usability was defined as those indicators and date of report, and the numerator and identified as high priority by the Inter-agency denominator values to calculate the indicator. Working Group on Reproductive Health in Analysis was conducted from November Crises [16]. For plausibility, if more than 10 2013-July 2014. The US Centers for Disease % of the monthly estimates had proportions Control and Prevention (CDC) conducted above 1 prior to cleaning, the data were 112 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

considered implausible and that indicator HIV postexposure prophylaxis (PEP) was not recommended for analysis. To avoid within 72 h of an incident occurring: redundancy, relevancy was determined based Number of rape survivors who receive on HIS indicators that have been previously PEP within 72 h of an incident / Total analyzed and published. number of rape cases reported. After reviewing the three criteria, the final selection of seven indicators was Data analysis determined by consensus of RH senior staff Data cleaning at UNHCR and CDC epidemiologists. The Within each country, the selected monthly seven indicators chosen for the analysis were HIS camp indicator variables (numerator and the following: denominator) were assessed for quality and 1. Maternal mortality ratio (MMR): cleaned. Quality was assessed for each of the Number of pregnancy-related deaths/ indicator variables by identifying monthly Total number of live births in a year × outliers by camp. For each indicator variable 100,000 in a given year. year, outliers were identified for each camp 2. Neonatal mortality rate (NNMR): if they varied by more than three standard Number of neonates who died before deviations from the yearly camp mean. If the reaching 28 days of age/Total number of flagged outlier was considered erroneous live births × 1,000 in a given year. after a review, a new value was imputed using 3. Proportion of births attended by a skilled average value of the month before and the birth attendant (SBA) (defined as doctors month after the outlier. Imputing for obvious or midwives who can diagnose and erroneous values versus setting them to manage obstetrical emergencies and missing allowed us to retain the monthly normal deliveries): Number of deliveries observations in the data set by giving it a attended by skilled birth attendant/ more probable value. Indicators were then Number of deliveries × 100. created from the cleaned numerators and 4. Proportion of live births performed by a denominators. The indicators with caesarian section: Number of live births proportions greater than 1 wererecoded to performed by Caesarian section/Number equal 1. of live births × 100. 5. Proportion of antenatal care (ANC) Statistical analysis mothers who were screened for syphilis For five of the indicators (syphilis screening, during pregnancy: At the time of delivery, skilled birth attendant, cesarean sections, Number of pregnant women who had PEP use and condom distribution), the unit been screened for syphilis during the of analysis was the monthly camp reports antenatal period/Total number of live by year within a country. To take into births × 100. account the lack of independence of 6. Rate of condom distribution within the camp monthly reports, the variance was entire population: Number of condoms computed using Taylor Series Linearization distributed per month/Total population. methods. Specifically, the SAS complex 7. Proportion of rape survivors who receive sampling procedures SURVEYMEANS, 113 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

SURVEYFREQ, SURVEYREG were used only available for maternal morality ratios in for the analysis to account for 2010 and 2013 [17, 18]. nonindependence. The yearly country indicator point estimates were computed by Results taking the mean of the monthly camp A total of 23 countries representing 145 estimates, and 95 % confidence limits were camps were evaluated for inclusion in the calculated to estimate precision. To test for analysis. Ten countries met the eligibility linear trends across years within a country, criteria and were included in the analysis. linear regression was used for continuous Nine countries were not included because variables. A p-value < 0.05 was considered they did not collect HIS data as early as 2008. significant for this analysis. Four countries were not included because Due to the small number of the camp three or more camps had more than 10 % of deaths per month, the unit of analysis within their monthly data missing. The ten eligible each country for the two mortality indicators countries, representing a total population of was the aggregated yearly camp reports. To 268,329, were the following: Bangladesh, calculate these indicators, the number of Chad, Djibouti, Kenya, Nepal, Tanzania, maternal or neonatal deaths and the number Thailand, Uganda, Yemen and Zambia. of live births from each camp was summed Tanzania and Djibouti were an exception, on a country level for each year. because they had only one camp reporting Population and live birth data was during the analysis period but the camp was averaged across years by country. Population considered acceptable. Within each country, data were used to compute the rate of camps varied in size and number. The condom distribution within the entire number of camps within a country may vary population. We used the number of live by month because camps may be missing a births to compute the maternal and neonatal monthly reportor may have opened or closed mortality rates, proportion of live births during the seven year time frame. Three performed by a caesarian section and camps were dropped from analysis (2 from proportion of ANC pregnant women who Chad, 1 from Kenya) because they had more were screened for syphilis during pregnancy. than 10 % of monthly data missing. The For all other indicators, the proportions for population in each camp could also vary each month were created from the camp widely during the analysis period (Table 1). monthly reported values before the analysis at a year and country level began. Mortality indicators We included maternal and neonatal Maternal mortality mortality rates obtained from the World Figure 1 shows the mean camp MMR for Bank development indicators by host each country and the host country MMR for country but not country of origin of the 2010 and 2013. Three live birth indicator refugee in our analysis. All rates were country estimates out of 3566 (0.08 %) were imputed aggregate rates. Data for neonatal mortality for the number of live births and used for rates were available for every year of the calculations in which live births was used; analysis; however, host country data were this included the neonatal mortality rate, 114 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

Table 1 Summary of population data and camps by country, 2007–2013

Country No. of camps No. of months Year HIS began Monthly camp populationa Monthly camp live birthsb of data implementation in country N =10 N =56 N = 3566 Mean Std Dev Median IQRc Mean Std Dev Median IQRc Bangladesh 2 154 2007 14,529 3,037 14,510 6,018 43.1 12.8 43 21 Chad 16 994 2007 17,953 7,960 17,362 9,505 57.1 47.6 53.5 49 Djibouti 1 71 2008 13,565 4,031 13,133 8,240 23.1 7.3 22 10 Kenya 5 412 2007 81,723 33,470 48,529 48,529 185.9 83.9 186.5 113 Nepal 2 105 2007 19,291 8,961 18,236 14,854 29.8 17.3 26 19 Tanzania 1 96 2007 57,850 8,262 60,591 12,320 177.8 35.6 174.5 45 Thailand 9 648 2008 15,907 11,474 15,825 10,274 36.4 27.7 33 26 Uganda 13 740 2007 15,333 16,884 8,302 16,380 39.2 51.8 15 51.5 Yemen 3 197 2008 20,314 7,307 21,770 7,965 40.3 17.8 39 17 Zambia 4 149 2008 11,864 4,245 10,687 5,335 49.2 109.2 31 31 aMean of monthly camp data for all years (2007–2013) bMean of monthly camp live births for all years (2007–2013) cInterquartile range

maternal mortality rate, proportion of births Neonatal mortality performed by Caesarian section, and The mean yearly camp neonatal mortality proportion of ANC women who were rates (NNMR) by country and the WHO screened for syphilis. There were no NNMR by host country are shown in Fig. 2. imputations for the number of maternal No values were imputed for the number deaths. The mean camp MMR was lower neonatal deaths. The mean camp NNMR than the host country MMR for all years and was lower than the country NNMR in every all countries, except for Yemen in 2010 and country for every year. The Nepal camp 2010 Thailand in 2013. Despite this trend, camp NNMR of 15.1 per 1,000 live birth rate was mortality rates varied by country and year. the highest of all country camp data over the Djibouti reported 526.3 and 416.7 maternal course of the study period. Yemen the deaths per 100,000 live births in 2008 and second highest camp NNMR over the study 2009, respectively, but did not report a period, 14.9 in 2010. Zambia’s mean camp maternal death after 2009. Kenya’s mean NNMR was the lowest of all countries with MMR was high from 2007 through 2013 0 in 2011 and 2013 and 0.3 and 0.9 in 2008 with a range across years of 198.5 through and 2009 respectively. In 2013, the biggest 301.5 maternal deaths per 100,000 live births. absolute difference between the refugee Chad and Uganda had lower MMRs than camp neonatal mortality rates and host many countries in the analysis, ranging neonatal mortality rates were in Chad (−38), between 53.3 and 129.8 and 42.8 and 195.9, Djibouti (−28), and Yemen (−21). The respectively. In 2013, the biggest absolute smallest difference was in Thailand (−1). difference between the refugee camp maternal mortality rate and host maternal Other reproductive health mortality rate were in Chad (881), Tanzania indicators (−410), and Djibouti (−230). The smallest The graphs below show the remaining five difference was in Thailand. indicators with the mean and the UNHCR 115 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

Fig. 1 Mean camp maternal mortality ratios (number of maternal deaths per 100,000 live births) by country and year (solid lines), compared with WHO host country maternal mortality ratios (dotted lines)

target values for each indicator. The text linear trend showed a significant increase describes significant trends. over time (p < 0.001). The percent of births attended by a skilled birth attendant Proportion of births attended by a increased significantly in 6 of 10 countries: skilled birth attendant Bangladesh (p < 0.001), Kenya (p = 0.0005), The plots in Fig. 3 show the yearly average Djibouti (p < 0.0001), Tanzania (p < 0.0001), of the monthly camp births attended by a Uganda (p = 0.0051) and Yemen (p = 0.010). skilled birth attendant for each country along Nepal experienced no change, and met the with the UNHCR target number of 100 % target indicator 100 % of the time over the coverage. Eight of the 3,566 (0.22 %) skilled study period. There was no significant linear attendant birth monthly values were outliers trend in 3 of 10 countries: Chad, Thailand, and imputed prior to creating the indicator. and Zambia. The percentage was above 100 % for this Proportion of live births performed by indicator in 270 out of 3566 (7.6 %) of the caesarian section monthly reports. On average most (8 of 10) Figure 4 shows the country-level results for countries did not meet the target of 100 % the average percentage of live births for all reporting years. The overall test for a performed by caesarian section by year. Nine 116 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

Fig. 2 Mean neonatal mortality rates (number of neonatal deaths per 1,000 live births in a year) by country and year (solid lines), compared with WHO host country rates (dotted lines)

of the 3566 (0.25 %) monthly values for this births performed by caesarian section over variable were imputed before analysis. The the study period: Bangladesh (p < 0.0001), WHO recommends to have between 5 % Djibouti (p < 0.0001), Kenya (p = 0.033), and 15 % of live births delivered through Nepal (p < 0.0001), Thailand (p = 0.029), caesarian section. The average monthly Tanzania (p < 0.0001) and Uganda caesarian section rates within refugee camps (p = 0.007). Zambia had a significant were below the recommended minimum for decrease in percent of caesarian section nearly half of countries every year (4 of 10 births over the study period (p = 0.038). countries), and an additional 2 countries only Chad and Yemen did not have any significant met the minimum once over the study change. period, Djibouti and Yemen, respectively. However, there was a significant linear trend Percentage of ANC mothers who were over time (p < 0.001), driven by two screened for syphilis during pregnancy countries Nepal and Tanzania, with a larger The yearly average of monthly camp syphilis increase in the percentage of caesarian screening by country is presented in Fig. 5. section deliveries. Seven of 10 countries had Nine of the 3,566 (0.25 %) monthly camp a significant increase in proportion of live values for the number of women who 117 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

Fig. 3 Proportion of births attended by a skilled birth attendant; UNHCR target is 100 % (dotted line)

received syphilis screening were imputed Nepal (p < 0.0001), and Thailand (p = 0.003). before the screening indicator was created. Two countries experienced a significant There were 731 out of 3,566 (20.5 %) camp decrease over the study period, Tanzania monthly reports equal to zero for the (p < 0.0001) and Zambia (p = 0.007). The antenatal syphilis screening, and 359 out of remaining 3 did not have a significant change 3,566 (10.1 %) of the monthly report in syphilis screening. proportions were over 1. According to the UNHCR target, 100 % of women who come Rate of condom distribution among the for antenatal care should be screened for population syphilis. Only 10 % of all countries for all The average yearly rate of camp condom reporting years reached the standard. There distribution per person per month can be was a significant increase in the yearly found in Fig. 6. Six variables were used to percentage of women screened within the create the numerator for the condom refugee camps in this analysis (p < 0.001). distribution indicator, and 491 values were Five out of 10 countries significantly imputed of 21,396 (2.3 %). In the increased the percentage of ANC mothers denominator, 22 of 3566 (0.62 %) of the screened for syphilis: Bangladesh (p = 0.008), total population values were imputed prior Chad (p < 0.0001), Djibouti (p < 0.0001), to the creation of the condom distribution 118 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

Fig. 4 Proportion of live births performed by caesarian section; UNHCR target is between 5 % and 15 %

indicator. There were 658 out of 3,566 (18.5 Proportion of reported rape survivors %) monthly camp values equal to zero for who receive PEP within 72 h of an the condom distribution indicator, meaning incident occurring that during those months there were either Figure 7 displays the proportion of rape no condoms available for distribution and/or survivors who were given PEP within 72 no condoms were distributed. Overall, the hours of a rape incident. Eight of 3566 (0.22 trend for condom distribution was not %) monthly values for women who received significant (p = 0.109). There was a PEP and eight of 3566 (0.22 %) of the significant increase in the rate of condoms women who reported rape were imputed distributed in 2 of 10 countries: Bangladesh before the PEP indicator was created. There (p < 0.0001) and Nepal (p < 0.0001). Three were 2971 missing values of 3566 (83.3 %) of 10 countries experienced a significant camp monthly reports for the PEP indicator decrease in the rate of condom distribution because there were no reported rapes within over time: Djibouti (p < 0.0001), Tanzania camps during those months. Only 10 % of (p< 0.0001) and Zambia (p < 0.010), and 5 all camps for all reporting years reached the of 10 had no significant change over time: standard, but there was a significant increase Chad, Kenya, Thailand, Uganda and Yemen. in the percentage of women receiving PEP

119 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

Fig. 5 Proportion of women screened for syphilis annually by country. UNCHR target is 100 %

globally (p < 0.001). One out of 10 countries instances standards were not met. Regardless had a significant increase over the study of improvements made in each country for period, Uganda (p = 0.0001). Six out of 10 each indicator studied, this analysis countries experienced no significant change demonstrates that more needs to be done to over time: Bangladesh, Chad, Kenya, Nepal, ensure women in refugee camp settings are Thailand, and Yemen. receivinghigh quality RH care, as this will decrease morbidity and mortality within the Discussion study population. It is often thought that This analysis provides an overview of analysis from the HIS is complete, reliable, important RH trends over the seven-year and of high quality. This analysis study period. For some indicators (births demonstrates a need for improved reporting, attended by a skilled birth attendant, as many countries were dropped from the caesarian section, syphilis screening, and study. To close this gap UNHCR and its PEP), improvement from 2007 is clear. For health partners need to improve strategies other indicators (MMR, NNMR, and and programs to derivemaximum benefit condom distribution), more information is from the HIS. needed to explain current trends and why or We suspect that HIS is not capturing if improvement is lacking. In several some of the maternal and neonatal deaths of 120 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

Fig. 6 Rate of condom distribution* in the population by year. *Figure depicts percentage (monthly rate*100)

the camp populations rather than over refugee camps, particularly when influxes of reporting live births or consistently achieving refugees due to an acute emergency occur very low maternal and neonatal mortality in during a protracted setting. An outbreak such these refugee camp settings. Several previous as Hepatitis E that occurred in Dadaab, studies onmaternal and infant mortality in Kenya disproportionally affected pregnant refugee camps discussed underreporting of women [20]. The maternal death audit maternal and neonatal mortality [19]; two system is a UNHCR strategy that has been recent studies that examine the extent of implemented successfully in Dadaab and underreporting of neonatal deaths have been includes community sensitization to report completed in camps in Tanzania and Chad deaths that occur at home [21]. Other [Idowu R, Morof D, Blanton C, Tappis H, interventions were also included such as Cornier N, Tomczyk B. Using capture- improvement of infrastructure, transport, recapture methods and verbal autopsy to supplies, skilled staffing and mother understand the incidence of neonatal incentives. This strategy could be replicated mortality, stillbirths and live births in in other camps. UNHCR refugee camps in Chad 2013. Ensuring SBA at delivery is efficacious in Unpublished report.]. Both neonatal and contributing to the reduction in maternal and maternal mortality can fluctuate within perinatal mortality and helping to reach the 121 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

Fig. 7 Proportion of rape survivors who received post-exposure prophylaxis (PEP) within 72 h of an incident occurring. UNHCR target is 100 %

post 2015 MDGs 4 and 5 targets [22, 23]. UNHCR and its partners provide refresher Overall, the significant increase across training and supportive supervision, as countries in this study is encouraging. Some needed. refugee camps in this study had a low use of Caesarian section was introduced in SBAs; this may be due to a lack of SBAs at emergency obstetric care as a lifesaving the facility level. Additionally, the procedure both for the mother and baby. proportions may have exceeded 100 % in Overall, there is a positive trend toward some instances because the live births were meeting the UNHCR standard of caesarean inaccurately recoded in the monthly reports section rates. It is known that the global or because host community women came to picture indicates an uneven distribution of deliver and were misclassified as refugees, but caesarian section that shows underuse in low more information is needed to determine the income settings and adequate or even root of the inaccuracies. An important unnecessary use in middle and high income consideration for maternity wards at all settings [24], and our analysis shows an camps is that they are staffed, 24 h a day, with uneven distribution depending upon the a professional midwife capable of country. The findings from Nepal are responding to common obstetric counterintuitive since it showed caesarian emergencies. It is also important that section rates that would reflect a high income 122 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

setting. Two studies have shown an inverse supply for testing and laboratories require association at population level between appropriately trained staff for testing [27, caesarian section rates and maternal and 28]. Improvements in UNHCR syphilis infant mortality in low income countries screening programs have included where large sectors of the populationlack implementation of a decentralized program access to basic obstetric care [25, 26], making of syphilis screening involving nurses trained thisindicator an important morbidity and in education, counselling and the provision mortality measure. In refugee camps where of on-site testing using the Rapid Plasma health care is provided and access to Reagin test and partner tracing [29]. emergency obstetric care may be Condom distribution was inadequate for disproportionately available, this study the majority of camps (6 of 9 camps were indicates there are still gains to be made in less than 50 % in 2013).When looking more maternal and infant mortality by increasing directly at the data, condom distribution was access to and use of improved birth sporadic and indicated months with high technologies, including cesarean delivery. In condom distribution and months with very addition, concerted actions need to be taken low to nocondom distribution. This indicator to offer timely caesarian section to women may not provide distinct value as a who need it and to advocate for a rationale measurement because distribution does not use of caesarian section in camps with a necessarily equate to use, especially where the surplus. In Chad and Zambiawhere caesarian product is given away free of charge. Refugee section rates were low more detailed field populations may also have a varying assessments would help to contextualize the proportion of childrenand/or females, issue and determine the best course of making comparisons across refugee action. Lastly, other important contributing countries difficult without adjusting for the factors that may increase caesarian rates such number of people who do not need as previous caesarian sections, and maternal condoms [30]. Logistical difficulties in or fetal causes if captured by the HIS could obtaining and delivering of supplies due to help to interpret this indicator. camp location do occur are major obstacles. Several factors could decrease the Refugee women who have experienced syphilis screening rate in refugee camps. For sexual violence should be referred for health instance, syphilis screening although a services as soon as possible after the routine part of ANC in refugee settings may incident. The large number of missing data be missed due to a lack of supplies, in this analysis points to the fact that either equipment and trained staff. Broader ANC very few women reported a rape in refugee may also be lacking, which indirectly leads to settings or the rapes were reported but not women not being screened for syphilis as recorded in the HIS, or women are not regularly as they should be. Finally, health willing to report a rape as a majority of the care providers may not be prepared in monthly reports did not indicate any rapes. syphilis prevention, and how to prevent re- The number of rapes reported in each infection during pregnancy by promoting country fall far below global statistics on condom use. Commodities may be in short sexual violence [31]. Legal reforms, 123 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

protection policy and high quality services limited to refugee camps and is facility-based. available to rape victims have been influential It may be biased because populations that do in increasing the likelihood that women will not seek care are excluded (survivors of report. Therefore, a multi-sectoral approach sexual violence, certain RH patients, and is needed in each refugee setting in order to deaths occurring outside of health facilities). improve services. It is recognized that in refugee camp settings, There were a number of limitations in women may have better access to quality RH this analysis [32]. Underreporting, lack of care than is available in their country of representativeness, lack of timeliness, and origin. The Global Evaluation of RH inconsistency of case definitions are four of Services for Refugees and Internally the most common limitations of many Displaced People, conducted in 2004 found surveillance systems. The HIS has been that internally displaced persons had worse implemented since 2006 and the quality and access to RH services than refugees [33]. completeness of data is known to be Thus we may anticipate that the results may somewhat variable during the first months suggest more positive findings than we might of using the system and may be variable find among the surrounding host population depending on conditions in the individual or internally displaced persons [34]. Ideally it camps and availability of human resources. would have been potentially helpful to have A number of countries were excluded from information on how the data were collected this analysis because the data was too in each health facility in each refugee camp variable. Camps from countries that were not in order to improve our understanding of the included in the analysis had a higher variance HIS RH data from this analysis to provide of reporting variability. Some camps rarely context to the results. reported and other camps within the same country reported fairly regularly. Another Conclusion limitation is that data quality may be Many of the refugee RH indicators have influenced by a number of factors that we been improving over time and most are did not measure such as newly opened camps better than those of host countries, but more versus long term camps, size of camps, can be done to improve the interventions to availability of RH services and staffing. The meet the UNHCR standards. More inclusion criteria were designed to limit the information is needed on the RH data amount of poor quality data, but they do not collection cycle to determine why there was ensure that all the monthly reports for 56 uneven distribution of indicators between camps were of high quality. It also should be countries. In general comprehensive, noted that we present the average monthly consistent and comparable statistics on RH camp estimates by year within a country, but provides an opportunity to assess progress there is variation within a camp and between towards indicator standards. Despite some camps within a country. Sensitive subjects, improvements over time, this analysis such as sexual violence may not be reported confirms that most countries did not meet accurately. standards and that there were differences in The UNHCR HIS in this study was RH indicators between countries and across 124 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

years. Consequently, the HIS periodic 2014. http://www.unhcr.org/pages/ monitoring of key reproductive health 49c3646ce0.html. Accessed 7 Mar 2015. indicators at the camp level should continue. 3. United Nations High Commissioner for Refugees. New UNHCR report says global forced displacement is at 18-year high 2013.http://www.unhcr.org. uk/news-and-views/news-list/news- Competing interests detail/article/new-unhcr-report-saysglobal-forced- The authors declare that they have no competing displacement-at-18-year-high.html. Accessed 22 interests. Feb 2015. 4. United Nations High Commissioner for Refugees Authors’ contributions JW, NC, CB and BT conceived of the study and Statistical Yearbook: Trends in displacement, designed the protocol. JW and MS led protection and solutions. Geneva: Switzerland implementation phase data collection; JW led 2011. http://www.unhcr.org/516282cf5.html. the data cleaning. JW and CB provided the data Accessed on 22 Feb 2015. analysis; JW, CB, PS and BT led the interpretation 5. Chynoweth SK. Advancing reproductive health on of the results and drafting of the paper. All the humanitarian agenda: the 2012–2014 global authors have read, provided input, and approved review. Confl Heal. 2015;9(S1):1. the final manuscript. 6. Tanabe M, Schaus K, Rastogi S, Krause SK, Patel P. Tracking humanitarian funding for reproductive Disclaimer health: a systematic analysis of health and The findings and conclusions in this report are protection proposals from 2002–2013. Confl Heal. those of the authors and do not necessarily 2015;9 Suppl 1:S2. represent the views of the Centers for Disease Control and Prevention/the Agency for Toxic 7. Krause S, Williams H, Onyango MS, Sami S, Substances and Disease Registry. Doedens W, Giga N, et al. Reproductive health services for Syrian refugees in Zaatri Camp and Irbid Author details City, Hashemite Kingdom of Jordan: an evaluation 1Rollins School of Public Health Grace Crum of the Minimum Initial Services Package. Confl Rollins Building, 1518 Clifton Road, Atlanta, GA Heal. 2015;9 Suppl 1:S4. 30322, USA. 8. Casey S. Evaluations of reproductive health 2 Emergency Response and Recovery Branch, programs in humanitarian settings: a systematic Division of Global Health Protection, Center for review. Confl Heal. 2015;9 Suppl 1:S1. Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 9. Casey S, Chynoweth SK, Cornier N, Gallagher MC, 30333, USA. Wheeler E. Progress and gaps in reproductive health 3United Nations High Commissioner for services in three humanitarian settings: Refugees, Case Postale 2500 CH-1211, Genève 2, mixedmethods case studies. Confl Heal. 2015;9 Dépôt, Switzerland. Suppl 1:S3. 10. Haskew C, Spiegel P, Tomczyk B, Cornier N, Herring Received: 2 February 2016 H. A standardized health information system for Accepted: 2 February 2016 refugee settings: rationale, challenges and the way Published online: 9 March 2016 forward. Bull World Health Organ. 2010;88:792–4. 11. Hershey C, Doocy S, Anderson J, Haskew C, Spiegel References P, Moss W. Incidence and risk factors for malaria, 1. UNHCR. Health Information System (HIS) Toolkit. pneumonia and diarrhea in chidren under 5 in 2010. http://www.unhcr.org/4a3374408.html. UNHCR refugee camps: a retrospective study 2011. Accessed on 18 Mar 2015. Confl Heal. 2011;5:24. 2. UNHCR. Using Data to Protect Refugee Health. 12. Doocy S, Tappis H, Haskew C, Wilkinson C, Spiegel

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P. Performance of UNHCR nutrition programs in 23. World Bank Births attended by skilled health staff post-emergency refugee camps 2011. Confl Heal. by country. http://data.worldbank.org/indicator/ 2011;5:23. SH.STA.BRTC.ZS. Accessed 3 Mar 2015. 13. Anderson J, Doocy S, Haskew C, Spiegel P, Moss 24. World Health Organization the Global Numbers and WJ. The burden of malaria in post-emergency Costs of Additionally Needed and Unnecessary refugee sites: a retrospective study 2011. Confl Caesarean Sections Performed per Year: Overuse as Heal. 2011;5:17. a Barrier to Universal Coverage. 2010. 14. Weiss WM, Vu A, Tappis H, Meyer S, Haskew C, http://www.who.int/healthsystems/topics/financing/ Spiegel P. Utilization of outpatient services in healthreport/30C-sectioncosts.pdf. refugee settlement health facilities: a comparison 25. Belizán JM, Althabe F, Cafferata ML. Health by age, gender, and refugee versus host national consequences of the increasing caesarean section status. Confl Heal. 2011;5:19. rates. Epidemiology. 2007;18:485–6. 15. SAS Version 9.3 Copyright ©. SAS Institute Inc. http://journals.lww.com/epidem/Fulltext/2007/ Cary: SAS Institute Inc; 2010. 07000/Health_Consequences_of_the_Increasing_ Caesarean.14.aspx. Accessed 1 April 2014. 16. Inter-agency Working Group on Reproductive Health in Crises Inter-agency Field Manual on 26. Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Reproductive Health in Humanitarian Settings. Thomas J, Van Look P, et al. Rates of caesarean 2010. http://iawg.net/resource/field-manual/. section: analysis of global, regional and national Accessed 28 June 2014. estimates. Paediatr Perinat Epidemiol. 2007;21:98– 113. http://ncbi.nlm.nih.gov/pubmed/17302638. 17. Neonatal mortality: Estimates developed by the UN Accessed 31 March 2015. Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA Population 27. WHO Global Health Observatory Data Repository Division). www.childmortality.org. Antenatal care (ANC) attendees tested for syphilis http://data.worldbank.org/indicator/SH. DYN.NMRT. at first ANC visit. http://apps.who.int/gho/data/ Accessed 6 Apr 2015. node.main.A1358STI?lang=en. Accessed 1 Feb 2015. 18. WHO Maternal mortality UNFPA, The World Bank, and the United Nations Population Division. Trends 28. Berman S. Maternal syphilis: pathophysiology and in Maternal Mortality: 1990 to 2013. treatment 2004.http://www.who.int/bulletin/ http://data.worldbank.org/indicator/SH.STA.MMRT/ volumes/82/6/433.pdf. Accessed 2 April 2015. countries?display=graph. Accessed 6 Apr 2015. 29. UNHCR HIV/AIDS and STI prevention and care in 19. Hynes M, Sakani O, Spiegel P, Cornier N. A study of Rwandan refugee campsin the United Republic of refugee maternal mortality in 10 countries, 2008– Tanzania. 2003. http://www.unhcr.org/4028afd34. 2010. Int Perspect Sex Reprod Health. 2012; pdf. Accessed 16 Jan 2016. 38(4):205–13. 30. Holmes K, Levine R, Weaver M. Effectiveness of 20. Mushahwar I, Hepatitis E. Virus: molecular virology, condoms in preventingsexually transmitted clinical features, diagnosis, transmission, infections. Bull World Health Organ. 2004;82:454– epidemiology, and prevention. J Med Virol. 61. http://www.ncbi.nlm.nih.gov/pmc/articles/ 2008;80: 646–58. PMC2622864/. Accessed 23 March 2015. 21. UNHCR Improving maternal care in Dadaab refugee 31. WHO, Department of Reproductive Health and camp. 2008. http://www.unhcr.org/4c247d969.pdf. Research, London School of Hygiene and Tropical Accessed 19 Jan 2016. Medicine, South African Medical Research Council. 2013. Global and regional estimates of violence 22. World Health Organization Making pregnancy against women.http://www.who.int/reproductive safer: The critical role of the skilled attendant. health/publications/violence/9789241564625/en/. 2004.http://www.who.int/maternal_child_adolesce Accessed on Feb 10, 2016. nt/documents/9241591692/en/. Accessed 1 Apr 2015. 32. Dartnall et al. Sexual violence against women: The scope of the problem. Best Practice & Researcg 126 Whitmill et al. Conflict and Health (2016) 10:3 DOI 10.1186/s13031-016-0069-6

Clnical Obstetrics & Gynaecology 2013;27:(1). doi: 10.1016/j.bpobgyn.2012.08.002. 33. Hynes M, Sheik M, Wilson H, Spiegel P. Reproductive Health Indicators and Outcomes Among Refugee and Internally Displaced Persons in Post emergency Phase Camps. JAMA. 2002;288:595–603. 34. Inter-Agency Global Evaluation of Reproductive Health Services for Refugees and Internally Displaced Persons. 2004. http://www.iawg.net/ resources/2004_global_eval/. Accessed 26 May 2015.

127 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

RESEARCH ARTICLE Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study

Abstract Introduction: Institutions play a central role in advancing the field of reproductive health in humanitarian settings (RHHS), yet little is known about organizational capacity to deliver RHHS and how this has developed over the past decade. This study aimed to document the current institutional experiences and capacities related to RHHS. Materials and Methods Descriptive study using an online questionnaire tool. Results: Respondents represented 82 institutions from 48 countries, of which two-thirds originated from low- and middle-income countries. RHHS work was found not to be restricted to humanitarian agencies (25%), but was also embraced by development organizations (25%) and institutions with dual humanitarian and development mandates (50%). Agencies reported working with refugees (81%), internally-displaced (87%) and stateless persons (20%), in camp-based settings (78%), and in urban (83%) and rural settings (78%). Sixtyeight percent of represented institutions indicated having an RHHS-related policy, 79% an accountability mechanism including humanitarian work, and 90% formal partnerships with other institutions. Seventy-three percent reported routinely appointing RH focal points to ensure coordination of RHHS implementation. There was reported progress in RHHSrelated disaster risk reduction (DRR), emergency management and coordination, delivery of the Minimum Initial Services Package (MISP) for RH, comprehensive RH services in post-crisis/recovery situations, gender mainstreaming, and community-based programming. Other reported institutional areas of work included capacity development, program delivery, advocacy/policy work, followed by research and donor activities. Except for abortion-related services, respondents cited improved efforts in advocacy, capacity development and technical support in their institutions for RHHS to address clinical services, including maternal and newborn health, sexual violence prevention and response, HIV prevention, management of sexually- transmitted infections, adolescent RH, and family planning. Approximately half of participants reported that their institutions had experienced an increase in dedicated budget and staff for RHHS, a fifth no change, and 1 in 10 a decrease. The Interagency RH Kits were reportedly the most commonly used supplies to support RHHS implementation. Conclusion: The results suggest overall growth in institutional capacity in RHHS over the past decade, indicating that the field has matured and expanded from crisis response to include RHHS into DRR and other elements of the emergency management cycle. It is critical to consolidate the progress to date, address gaps, and sustain momentum.

128 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

Introduction In 2004, the IAWG conducted a ten-year Approximately 51 million people are global evaluation of RHHS through a series displaced by conflict and persecution [1]. of nested studies to identify gaps and Another nearly 22 million are internally constraints to inform resource planning and displaced due to the sudden onset of a interventions for partners [11]. Findings natural disaster [2]. As the majority of showed that RH services were generally countries with the highest maternal and favorable for refugees in stable settings but neonatal mortality are affected by crises [3,4], were lacking for the internally displaced. The addressing the sexual and reproductive health 2004 Global Evaluation studies included an needs and rights of affected women, men assessment of organizational changes since and adolescents is critical to ensuring their 1995, focusing on agencies involved in wellbeing, achieving the Millennium RHHS. The major areas covered by that Development Goals (MDGs) 4,5, and 6, and study included RH program components; the post-MDG agenda. Following the Balkan organizational operations and policies; RH crisis and since the mid-1990s, reproductive training and capacity building; technical health in humanitarian settings (RHHS) has assistance; resource tools; financial and staff been progressively mainstreamed into resources; and collaboration between international standards [5]. The Inter-Agency agencies. An important objective of the Working Group on Reproductive Health in assessment was to document the level of Crises (IAWG) was formed in 1995 with the commitment that organizations gave to the mission to expand and strengthen access to following five objectives of the MISP and quality RH services for people affected by the different types of work they undertook conflicts and natural disasters. The IAWG to support these objectives: 1) ensure established the global cornerstones for effective coordination; 2) prevent sexual implementing RHHS: the Minimum Initial violence and provide clinical care for Service Package for Reproductive Health survivors; 3) reduce HIV transmission; 4) (MISP), the Inter-Agency Field Manual on prevent excess maternal and neonatal Reproductive Health in Humanitarian morbidity and mortality; and 5) plan for Settings (IAFM), and the Inter-Agency comprehensive RH services [6]. In addition Reproductive Health Kits [6–8].Over the to the MISP, the study reviewed the past decade, the MISP has been included in components of comprehensive RH based on key global health governance and funding the 1999 version of the IAFM, which processes that have given RHHS higher included safe motherhood, gender-based priority. These include the “cluster violence (GBV), sexually-transmitted approach” put forward by the 2005 infections (STIs), family planning (FP), and Humanitarian Reform to enhance leadership, HIV [7]. Since 2004, the demonstrated trend accountability and predictability in of growth in capacity for technical expertise, humanitarian response [9], and the Central collaboration, program activities, and Emergency Response Fund (CERF) of institutionalizationof the RHHS agenda has which the MISP meets the life-saving criteria continued in many organizations, and the [10]. number of tools and resources to guide 129 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

RHHS programming has increased over the Materials and Methods last decade [12,13]. Greater attention has also We undertook a descriptive study using a been given to building national resilience to questionnaire tool with open and closed and preparedness for emergencies [14]. The questions. The purpose of the questionnaire aid architecture, as emphasized by the Paris was to capture data about and gain insight Declaration and Accra Agenda of Action, into institutional capacity for RHHS along has shifted toward country ownership and the emergency to development continuum empowerment [15]. The new RHHS including DRR, crisis response, early developments in disaster risk reduction recovery and re-development, with trends in (DRR) including emergency preparedness, organizational changes over time. The early recovery, and protracted crises indicate questionnaire employed a structured IAWG’s growing efforts to bridging the theoretical framework based on Kaplan’s humanitarian and development divide to theoretical capacity building model [17]. ensure a more holistic, sustainable, and Capacity, for the purpose of this study, is effective approach to health emergency defined as the ability of an organization to management and health system function as a resilient, strategic, and strengthening efforts (emergency autonomous entity [18]. The six elements of preparedness is a component of DRR; it is the capacity building model include mentioned separately in this study as institutional policy, accountability DRR/emergency preparedness as many mechanisms, delivery strategy, and financial, countries have addressed it, but not the other human and technical resources related to components of DRR, which are referred to RHHS (Fig 1). These components of as DRR/other components) [14,16]. institutional capacity can serve as proxy Anecdotal evidence suggests that more indicators of the overall state of RHHS and agencies have institutional policies related to be helpful in illustrating how new approaches RHHS, which also encompass broader entry to addressing RHHS and institutional points for RHHS, including DRR, commitment to capacity development have emergency response, and during protracted been addressed at the field level. This study crises or early recovery. However, little is interpreted Kaplan’s conceptual framework known about the extent of institutional as an institutional framework, which could capacity and commitment to RHHS since the comprise policies, guidelines, or other official 2004 Global Evaluation. Therefore, as part supporting documents for RHHS. According of the 2013–2014 global evaluation of to Kaplan, organizations are more likely to RHHS, the IAWG designed this study. It enable capacity building if they focus on aims to gain insight into the overall state of developing an appropriate institutional RHHS over the past decade from an framework that is driven by a concordant institutional perspective, by describing the organizational attitude, vision, strategy, and capacity of government, non-government, supportive structures. United Nations, humanitarian, and Therefore, the questionnaire tool was development institutions to address RHHS. comprised of the following major components: purpose of the survey and 130 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

consent, institutional characteristics, 1. A conceptual framework that reflects the institutional policy, accountability institution's sense of purpose about the mechanisms, program delivery strategy, critical importance of the issue at stake — structures and procedures, workforce here, RHHS. 2. Accountability mechanisms that reflect the competencies, and most useful material acceptance of responsibility to perform and resources. The questionnaire tool was field- deliver according to international standards tested with selected institutions working at and guidelines. The questions related to country and global level, and modifications accountability were directly drawn from the were made based on this feedback. Ethical accountability section of the IAFM and approval to carry out the study was obtained asked whether institutions were abiding by from the Faculty of Health of the University humanitarian standards, such as those Technology, Sydney Australia (Nil/Neg defined in the Sphere Humanitarian Risk—UTS HREC 2013000209). The final Charter and Minimum Standards in Disaster Response and other Inter-agency questionnaire can be viewed online [19]. The Standing Committee (IASC) Guidelines [7]. English version was translated into French In addition, the questionnaire asked and back-translated into English to ensure whether key steps to foster accountability veracity. Both English and French versions were taken by institutions, such as engaging were administered online from April to the beneficiary participation in all August 2013 using the Smart-Survey programming steps, or enforcing systems software. A hard-copy of the questionnaire within an organization to respond to was made available to respondents with improper conduct by staff 3. A delivery strategy that flows out of the limited internet access. A quantitative recognized responsibility and reflects how descriptive design was adopted in order to and what will be delivered over a specific gain a broad yet critical insight into the period of time, such as coordination, phenomenon of organizational capacity partnership, areas of work in RHHS, and development in RHHS [20]. The target components of RH services. population comprised humanitarian 4. Defined and differentiated organizational institutions working in health or institutions structures and procedures that reflect and working in RH and/or RHHS. Criterion support the strategy, such as human resources for health, financial resources, or sampling was used with organizations standard operating procedures. selected according to their membership of 5. Relevant individual skills, abilities and key groups involved in RHHS competencies, such as workforce [21].Therefore, the questionnaire was sent to competencies. the listservs of the IAWG (n = 1292, 6. Sufficient and appropriate material resources, representing 723 institutions), CORE Group such as guidelines, protocols, RH supplies, (n = 1875, representing 354 institutions) [22] and kits. and Global Health Cluster (n = 118, Fig 1. The six elements of the representing 46 institutions) [23]. It was theoretical framework on assumed that some institutions may be institutional capacity applied in this represented in more than one of the three research, based on Kaplan [17] listservs. But due to confidentiality concerns, doi:10.1371/journal.pone.0137412.g001 131 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

it was not possible to obtain the detailed list IBMSPSS Statistics 21. Data validation was of institutional names of each listerv to donemanually and through frequency checks exclude double entries, and therefore and cross-tabulations. Descriptive statistical calculate the total number of unique analysis was undertaken on all variables. Chi institutions that were invited to participate in squared tests were undertaken on cross the survey and determine the corresponding tabulations. Responses to the open questions response rate. As this is a descriptive study were collated and summarised. design using an online questionnaire tool, our hope was to receive at least a similar number Results of responses from institutions as the number Characteristics of respondents in the 2004 global evaluation (n = 30) and Eighty-two institutions from 48 countries that participating institutions would not participated in the study (Fig 2), of which originate mostly from the global level as it two thirds originated from low- and middle- was the case in 2004 but also come from income countries from Sub-Saharan Africa country and field levels. We invited all and Asia Pacific, and, to a lesser extent, the organizations to complete a questionnaire Middle East and Northern Africa, Eastern and analysed the results using descriptive Europe and Central Asia, and Latin America statistics. Based on the IAWG experience, and the Caribbean. Results indicate that most institutions with the same name and working respondents held high-level management at different levels (national, regional, global) positions, as suggested by their job titles: and in different countries often have head, director, coordinator, specialist, different capacities and were assumed in this manager, representative, professor or study to differ in their capacities and were assistant-professor, focal point, and others handled as independent units of analysis. (Table 1). Fifty percent of institutions were Therefore, each institution was invited per NGOs, 34% United Nations agencies, 9% questionnaire instructions to select themost governmental institutions, and 7% academic competent individual to represent their institutions, with 71% of them working organization at the respective national, primarily at field and country levels. A large regional and international levels and proportion of institutional respondents participate in the research from the reported being members of the IAWG perspective of the level where they worked (85%). Chi-squared tests on cross-tabulations only. Consent was obtained from participants of variables in this section and all the other at the beginning of the questionnaire and sections did not show any significance. respondents had the option to exit it at any time. Targeted follow-up by email was Nature of work carried out to encourage responses from Twenty-five percent of institutional members of institutions in countries that had respondents reported the nature of their experienced humanitarian emergencies over work to be primarily humanitarian, 25% the past decade but that had not yet primarily development, and 50% had an answered the questionnaire. The data was equal dual focus (Table 1). The majority of extracted and transferred for analysis onto respondents reported that their institutions 132 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

worked primarily at field or country level humanitarian focus reported having a (71%), 7% at the regional level, and 22% at RHHS-related document (82%), respondents the global level, with 93% dealing with from development institutions also indicated capacity development (e.g. technical that they were supported by an RH policy assistance, training), 85% with program (61%). Emergency response was the most delivery (e.g. coordination, clinical delivery), commonly reported policy content (91%), 81% with advocacy and policy work, 54% followed by DRR/emergency preparedness with research, and 39% with donor activities. (72%), recovery (63%), DRR/other Respondents said their institutions operated components (42%), and research policies not only in camp-based settings (78%), but (25%). also urban (83%) and rural settings (78%); with the affected populations they served Accountability being not just primarily refugees (81%), but Seventy-nine percent of respondents also internally displaced persons (IDPs) reported that their institution had an overall (87%) and stateless persons (20%). accountability mechanism that also covered humanitarian work, 13% did not have one Institutional framework and the remainder did not know. A vast Two thirds of respondents (68%) reported majority of respondents stated that their their institution having an RHHS-related institutions had policies and systems in place policy or guideline, or other official support to comply with global standards, such as the document, such as a Board mandate, 23% IASC Guidelines for Gender-based Violence reported not having such a document, and Interventions in Humanitarian Assistance the remainder did not know. Although most and others [5,7,24–31]. In addition, respondents from institutions with a respondents noted that their institutions had

Fig 2. Map of the 48 countries from where the 82 institutional respondents originated

doi:10.1371/journal.pone.0137412.g002 133 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

Table 1. Characteristics of respondents (n = 82) and nature of work

Distribution of respondents by geographical region (%) Australia, Western Europe countries, USA 33 Sub-Saharan Africa 29 Asia Pacific 24 Middle East and Northern Africa 7 Eastern Europe and Central Asia 5 Latin America and Caribbean 1 Types of institution (%) Non-governmental organisation 50 United Nations 34 Government 9 Academia 7 Membership to IAWG (%) Yes 85 No 9 Don't know 5 Level of work (%) Primarily global level 22 Primarily regional level 7 Primarily field/country level 71 Nature of work (%) Primarily humanitarian 25 Primarily development 25 Both humanitarian and development 50 Types of settings where institutions work (%) Camp 78 Rural 83 Urban 83 Crisis-affected populations institutions work with (%) Refugees 81 Internally displaced persons (IDPs) 87 Stateless 20 Areas of reproductive health in humanitarian settings addressed by institutions (%) Capacity development (e.g. technical assistance) 93 Program delivery (e.g. coordination, clinical services) 85 Advocacy/policy 81 Research 54 Donor activities 39

doi:10.1371/journal.pone.0137412.t001 134 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

mechanisms in place to ensure that a number in institutional coverage, with the most of steps were taken with regard to activity occurring in relation to MISP accountability. These include: RH indicators implementation, capacity development, and collected as part of the institutional health technical assistance, with approximately half information system and/or monitoring and of the institutions having started such evaluation system (86%); engagement of activities in 2004 or after (Fig 3). Growth was beneficiaries in all programming steps— also reported in RHHS-related assessing, planning, implementing and DRR/emergency preparedness, emergency monitoring the project (70%); compliance management and coordination, delivery of with systems within the organization to comprehensive RH services in post- respond to improper conduct by staff (69%); crisis/recovery situations, recovery, gender the establishment of ongoing mainstreaming, DRR/other components, communication with affected populations advocacy and policy work, and community- about the institution and its project plans and based programming (most notably in the work (69%); and the institution of areas of FP, GBV, and maternal and mechanisms for beneficiaries to contact newborn health). organizational representatives, lodge RH services. The results show complaints and seek redress (49%). increased activity over the past decade in almost all clinical areas of work in the Program delivery strategies institutions from where participants were Partnerships and coordination. A drawn (Fig 4). These clinical areas were not majority (90%) of respondents reported that exclusive to service provision and could their institution participates in RH involve guideline development, service coordination mechanisms or working groups delivery, technical assistance, training, and 73% reported that their institutions advocacy, or research. Increases in the routinely invested in an RH focal point or institutional coverage of a number of areas officer to ensure effective coordination of were noted by respondents including MISP- the MISP. The leading coordinating related services and some comprehensive institutions were the UN (85%), government RH services: maternal and newborn health, agencies (62%), and NGOs (58%). sexual violence prevention and response and Institutions reported to hold formal broader GBV prevention, HIV prevention, partnerships with the following other management of sexually-transmitted institutions working in RHHS: UN agencies infections (STIs) or reproductive tract (71%), government institutions (62%), infections (RTIs), adolescent RH, and FP, international NGO (62%), national NGO including emergency contraception. Results (56%), community-based organizations indicate that respondents felt that institutions (41%), and private sector (15%). had increased the delivery of HIV care and Areas of work. Results indicate that support including ARV interventions since from 2004, almost all of the areas of work 2004, but overall, the findings show that this related to RHHS were reported by area of activity had less institutional coverage participants to have experienced an increase than other components of RH care, despite 135 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

the fact that the MISP recommends the abortion services (35%). As for FP, provision of ARVs for individuals already institutions reported providing not only taking them and for PMTCT. According to short-term methods (88%, e.g. pills, respondents, institutions were less active in condoms, injectables), but also emergency terms of abortion-related services, which are contraception (77%), longacting FP methods part of the MISP, cervical cancer screening (79%), and postpartum FP (70%). and treatment, and permanent methods of Permanent FP methods were reportedly FP, which are components of addressed by 53% of institutions. With comprehensive RH services. With regard to regard to cervical cancer screening, abortion-related services, half of all approximately half of respondents said their respondents (49%) reported that their organizations did not undertake screening institutions did not conduct activities related (46%) or provide treatment (52%). to induced abortion, and approximately a third did not address post-abortion care Financial resources (29%), or referral to safe abortion or post- The 2004 Global Evaluation reported an

Fig 3. Areas of work in reproductive health in humanitarian settings addressed by institutions before and since 2004 (n = 82) 136 doi:10.1371/journal.pone.0137412.g003 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

increase in the overall organizational advocacy/policy work, and to a lesser extent expenditure for RHHS over the previous research, while 20% did not report decade though it did not reflect an overall substantial change and 13% reported a global increase in funding for RHHS. The decrease (Fig 5). 2013 results show that the overall trend in organizational expenditure has continued Human resources after 2004 for half of the respondents (49%) Although 22% of respondents reported no and concerned DRR, response, recovery, change in the number of dedicated staff to

Fig 4. Clinical reproductive health in humanitarian settings services addressed by institutions before and since 2004 (n = 82) doi:10.1371/journal.pone.0137412.g004 137 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

RHHS over the past decade, and 15% a that are needed to supportMISP decrease, 50% reported an increase, with a implementation. In the previous five years, growing number of staff having moderate to respondents indicated experiencing the high levels of competencies (Fig 6). These following challenges with regard to the competencies include the MISP, gender- procurement of RH supplies: delay in mainstreaming and other components of the obtaining or distribution of Interagency RH emergency management cycle such as DRR Kits (81%), difficulty in sourcing quality RH and recovery. supplies (56%), delay in identifying suppliers for RH commodities (49%), and stock out Guidance of RH supplies (21%). There is a wealth of materials related to RHHS [12,13]. Among the 21 publications Discussion that institutional respondents had to rank, The results suggest an overall picture of the landmark IAFM stood out as the most growth in institutional capacity in RHHS useful publication. This document and the over the past ten years. This progress is other top five most useful publications illustrated across a number of areas, support the field implementation of the including: involvement of institutions that MISP [6,7,8,32,33]. Except for the Sphere are not primarily humanitarian; inclusion of Handbook [5], the publications ranked six to other beneficiaries and in new contexts, such ten focus on a specific topic, including GBV as IDPs, stateless persons, and urban and adolescent RH [24,34,35,45]. With settings; establishing institutional frameworks regard to guidance that institutional for RHHS; setting up accountability respondents wished that the IAWG develops mechanisms supporting RHHS; and working to support their RHHS work and workforce through partnerships and broadening in the next five years, monitoring and program delivery strategies to integrate DRR evaluation, research, documentation and and the emergency management cycle (Table dissemination on RHHS came on top, along 2). Additional areas include: improving the with DRR/emergency preparedness, quality and comprehensiveness of clinical advocacy and policy work, and emergency services, although key services are still not management and coordination. sufficiently prioritized, such as abortion- Commodities Respondents noted that related services; and reinforcing investments institutions concerned with service delivery in dedicated human and financial resources and/or the procurement of RHHS for RHHS. However, the results of this commodities reported using the Interagency research need to be carefully interpreted as Reproductive Health Kits (65%), which are they only allow us to glean some insight into designed and regularly updated by the IAWG self-reported organizational capacity, which and directly support MISP implementation does not reflect quality of or access to [8]; local or regional supply chains (51%); services on the ground. their institution’s supply chain (34%); and the It is worth noting the global reach of the Interagency Emergency Health Kits (23%), study although only a few responses came which include some RH supplies, but not all from the Middle-East and North Africa 138 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

Fig 5. Proportion of institutions with dedicated budget for areas of work related to reproductive health in humanitarian settings by time period (n = 82) doi:10.1371/journal.pone.0137412.g005

region. This is less than what would be approach to addressing RHHS within the expected in light of the several crises in that emergency management cycle in which region over the past years, and may be due to humanitarian and development institutions the fact that the questionnaire tool was only alike have a joint role to play [14]. The available in English and French. The high inclusion of programs involving not only proportion of institutional respondents with refugees, but also IDPs and stateless persons IAWG membership may reflect the IAWG’s contrasts with the 2004 results, which successful outreach and scalingup efforts indicated that services for IDPs were over the past decade to strengthen country severely lacking, and where there was no and regional capacity and ownership in mention of stateless persons. RHHS. Adopting an institutional framework With regard to the nature of work of for RHHS can serve as a roadmap and institutions, results suggest that RHHS is no help catalyze the prioritization and longer a sole domain for humanitarian implementation of RHHS activities within institutions. This may reflect a shift in the an organization. The findings indicate that landscape of RHHS where increased over the past decade, and in particular during emphasis has been placed on a holistic the 2010–2012 period, there has been an 139 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

Fig 6. Proportion of institutions reporting high-level workforce competencies in different areas of reproductive health in humanitarian settings by time period (n = 82) doi:10.1371/journal.pone.0137412.g006

increase in the number of institutions, either results suggest that this movement has also primarily humanitarian or development, been reaching many institutions working in supported by an RHHS-related policy, RHHS, with a majority of them having guideline or other official support mechanisms in place to abide by such documents, such as a Board mandate. This principles. Institutions with a presence at the suggests progress in institutionalizing RHHS field and regional level may rely on the considering that in 1995, when the IAWG accountability mechanisms established by was formed, only one institution had an their headquarters; the extent to which these RHHS policy, and in 2004, 43% of those mechanisms actually inform field-level surveyed had an RHHS policy [11]. programming require in-depth assessments There has been a movement in the that were not part of the scope of this study. humanitarian community towards ensuring Therefore, further research is needed to accountability to recipients of assistance, as examine the nature and extent of illustrated by the development of accountability mechanisms adopted by international standards, especially the Inter- institutions and how they actually influence Agency Standing Committee (IASC) program implementation in the field. guidelines and the Sphere Handbook and In terms of program delivery strategies, other major principles of accountability. Our results indicate that partnerships and 140 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

Table 2. Institutional capacity for RHHS in the 2004 and 2013 global evaluations: summary of key findings.

2004 global evaluation 2013 global evaluation Participating institutions Mostly humanitarian institutions Humanitarian and development from the “global North” (n = 30). institutions with a majority of them based at field/country level (n = 82). Institutional policies Less than half of institutions (43%). A majority of institutions (68%). supporting reproductive health in RHHS Accountability mechanisms Not assessed. A majority of institutions (79%). related to RHHS Target populations Mainly refugees. Refugees, internally displaced persons, stateless persons. Main services focused upon More than half reported a focus on MISP within a wider disaster risk safe motherhood including emergency reduction and emergency preparedness obstetric care, GBV, HIV, STIs, FP; and framework; STIs and adolescent RH. youth programs. Main gaps in services Half or less reported to focus on MISP, Post-abortion care and comprehensive female genital mutilation, sexual violence abortion care services, permanent including sexual exploitation and abuse, methods of contraception, and domestic violence, ART including PMTCT, cervical cancer screening and treatment. and emergency contraception. Institutional budget for RHHS Overall growing investment. Overall growing investment. Institutional human resources Overall growing investment (86% Continued investment (50% of for RHHS of respondents reported increase). respondents reported increase, 22% no change, and 15% reported a decrease).

ART: antiretroviral therapy, FP: family planning, GBV: gender-based violence, MISP: minimum initial service package for reproductive health, PMTCT:prevention of mother-to-child transmission of HIV, RHHS: reproductive health in humanitarian settings, STIs: sexually-transmitted infections. doi:10.1371/journal.pone.0137412.t002

coordination remain critical, reflecting the of the 2012–2014 IAWG global evaluation findings of the 2004 survey where formal [36, 37]. partnerships and interagency coordination Service delivery appears to be hampered were found to be key elements. As for the by challenges with timely access to RH areas of work, institutions appear to keep an supplies which is also consistent with the emphasis on core activities, such as MISP IAWG field study in three humanitarian implementation, capacity development, and settings [38]. Respondents’ views on their technical assistance while results also suggest institutional capacity to make other FP the development of work in emerging areas, methods, such as emergency contraception, such as DRR. Increased commitment to long-acting and postpartum methods, implementing the MISP is also reflected in increasingly available in RHHS programs are the MISP assessment and funding studies encouraging and show increased activity 141 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

compared with the results of the 2004 or did not change substantially for a majority Global Evaluation, which highlighted gaps of institutions. This is a positive finding in related to the availability of methods [11]. spite of the global financial crisis of 2008 However, other global evaluation studies and its aftermath, and demonstrates the show emergency contraception and long- importance and commitment given to acting FP methods a gap [38], which may RHHS by institutions, including donors [39]. reflect agencies focus in these areas on The fact that almost three quarters of advocacy and capacity development with a institutions reported routinely investing in an time-lag between what agencies are aiming to RH focal point or officer is also encouraging implement and what they are actually since past MISP implementation assessments managing to do. As expected, components have frequently highlighted weak of comprehensive RH that are more coordination that was partially due to the lack complex in terms of programming or that of a dedicated RH focal point [40]. The 2004 were recently included in the IAFM, such as Global Evaluation further pointed to the lack safe abortion care, ARV provision, PMTCT, of agreement among respondents on the cervical cancer screening and treatment, and definition of RH focal point. This situation permanent FP methods, received less has now been clarified and the IAWG has reported institutional coverage and are terms of reference for the RH focal point consistent with other global evaluation that were added to the 2010 revised version studies [36, 38]. These findings highlight the of the IAFM to help implementing partners needs for the IAWG to develop a well- address this critical step [41]. Since the mid- planned and well-resourced strategy to tackle 2000s, several global initiatives have been these gaps. In particular, emphasis needs to established that may have contributed to the be given to the delivery of safe abortion care overall workforce strengthening in RHHS, as part of MISP implementation. The including: the RAISE Initiative [42], the inclusion of a new Comprehensive Abortion SPRINT Initiative [43], several training Care chapter in the 2010 revision of the courses on sexual violence [44–46], and the IAFM is a remarkable step forward. Other MISP Distance Learning Module, which RH services that were found to receive less more than 4,000 people have completed focus, such as the provision of ARVs for online since 2006 [6,47]. continuing users or for PMTCT, cervical With regard to guidance, the IAFM cancer screening and treatment, and stood out as the most useful publication permanent FP methods, also need to be along with the ones supporting the field addressed. Overall, however, these findings implementation of the MISP. The fact that suggest progress towards building guidance materials related to managing GBV institutional capacity with regard to RHHS and adolescent RH were also ranked highly services. illustrate the importance given to addressing The positive development of these critical gaps. Adolescent RH is a cross- institutional capacity globally is also cutting but often overlooked theme in suggested by the overall trend in organization RHHS [48]. Partners should take note of the expenditure which has continued after 2004 wealth of existing materials related to RHHS, 142 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

To consolidate progress to date, the IAWG members and other stakeholders in RHHS should focus on collective actions to further facilitate the capacity strengthening of countries and partners over the coming years. This includes the following: 2 Continue the outreach efforts by holding annual work meetings on RHHS in the regions and supporting regional working groups. The regionalization of the IAWG has been instrumental in disseminating globally the MISP standards as well as tools and best practices to support its implementation. 2 Establish an effective and responsive coordination structure for the IAWG with dedicated financial and human resources. As the number of institutions working on RHHS grows worldwide, it is important to continuously support their capacity development. 2 Revitalize the IAWG Capacity Development Partnership and equip it with adequate resources to ensure that staff and institutions in the field can develop the capacities they require to implement RHHS. This Partnership can tackle critical topics such as DRR, coordination of RHHS, and the transition from MISP to comprehensive RH, for which there is currently very limited training materials. These topics are critical to strengthening local health systems from preparedness planning to response, recovery and re-development phases. 2 Continuously address gaps in service delivery and improve quality and access. Particular attention needs to be given to abortion-related services and other RH services found to receive less attention, such as the provision of ARVs. 2 Systematically identify a lead agency and its RH focal point to lead RH coordination in all humanitarian emergencies and support the development of a surge capacity to support RH coordination as needed. Effective coordination is paramount in emergency and key tasks of the RH focal point should include, among others, strengthening the RH supply chain management and facilitating the field implementation of accountability mechanisms. 2 Support and undertake research on RHHS. Research, such as the global evaluation, has been instrumental in monitoring progress and identifying gaps and opportunities related to RHHS. The field is expanding with new frameworks and strategic approaches that would benefit from thorough documentation and study in order to provide sound evidence to inform policies and programmes. 2 Increase advocacy efforts to engage both development and humanitarian sections among donors, governments and non-governmental organizations. As reflected in the results of this research, institutions are giving increased emphasis to a holistic approach to addressing RHHS within the emergency management cycle in which humanitarian and development institutions alike have a joint role to play. Therefore, donor alignment and harmonization with regard to their RH-related policies, funding and programs along the emergency management cycle will maximize impact on the ground and help bridge the divide between the humanitarian and development fields.

Fig 7. Policy and program implications of the study for the global public health community

143 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

asdesigning guidance and training resource humanitarian emergencies and RHHS packages to develop workforce capacity is interventions in all communities covered by resourceconsuming and should be participating institutions. However, the study thoroughly planned and evaluated from suggests capacity growth across a number of design to implementation phases. institutions. Further research is needed to Results suggest that the Interagency RH examine whether this reflects trends across Kits remain the most commonly used source all institutions and the relationship between of supplies (along with other local, regional, factors that help to facilitate institutional and global sources), but that the timely capacity development. The reported changes distribution of the kits in-country remained in organizational capacity over time are a major challenge. Although multiple face-to- general descriptions relying on institutional face logistics training workshops were memory, which participants may have had conducted over the years by IAWG partners, difficulty recalling. To follow trends in real further studies are needed to examine and time requires repeated representative cross address the commodity barriers and sectionalsurveys at different points in time, challenges reported byrespondents. which can be expensive and time-consuming. The current findings will also be useful as a Study limitations reference for assessing progress in The results of this research provide a institutional capacity when future evaluations snapshot of self-reported organizational will take place, including the next Global capacity development among the Evaluation that will likely occur again in ten participating institutions and does not equal years. to action on the ground or reflect quality of services. Non-probability sampling means Conclusions that the results of this study are not The results suggest growth in institutional representative and reflect the views and capacity in RHHS but further research is experiences of those who participated. needed to examine the nature, quality and Respondents may have had more interest in extent of this progress. Overall, there are RHHS than non-respondents which may encouraging indications that the RHHS field have led to a lack of perspective from may have matured. It is therefore critical to organizations without this focus. However consolidate the progress to date, address this in itself may indicate that more work is identified gaps, and sustain the momentum to be done to further engage organizations of ongoing improvement (Fig 7). in RHHS. Further, agency representatives may have reported intentions given their engagement in internal dialogue or Supporting Information coordinated efforts, and not necessarily S1 Data Set. Data set on institutional capacity for service delivery that had actually begun. reproductive health in humanitarian settings. (PDF) The responses exclude the inputs from those unable to complete the questionnaire Acknowledgments in English or French and do not represent all The authors thank Valérie Wizard for managing 144 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

the online questionnaire tool, Rainer Tan and Received: 17 January 2015 Seher Shafiq for research support, and all of the Accepted: 17 August 2015 agencies and individuals who contributed to Published: 2 September 2015 the study. This study was conducted on behalf of the Inter-Agency Working Group (IAWG) Copyright on Reproductive Health in Crisis Situations © 2015 Tran et al. This is an open (www.iawg.net). access article distributed under the terms of the Creative Commons Attribution License, which The core institutional members of the Inter- permits unrestricted use, distribution, and Agency Working Group (IAWG) on Reproductive reproduction in any medium, provided the Health in Crisis Situations are: Heather Buesseler, original author and source are credited. American Refugee Committee (ARC); Carolyn Baer, CARE; Michelle Hynes, Centers for Disease Data Availability Statement Control and Prevention; Therese McGinn, All relevant data are within the paper and its Columbia University–The Heilbrunn Department Supporting Information files. of Population and Family Health; Janet Meyers, International Medical Corps; Martin Migombano, Funding International Planned Parenthood Federation; US Department of State, Bureau of Bill Powell, Ipas; Ashley Wolfington, Population, Refugees and Migration: International Rescue Committee; Hannah Tappis, http://www.state.gov/j/prm/. Jhpiego; Melissa Sharer, John Snow, Inc.; Lydia The John D. and Catherine T. MacArthur Ettema, Marie Stopes International; Allie Foundation: http://www.macfound.org/. Doody, Population Action International; Ribka The funders had no role in study design, data Amsalu, Save the Children; Heather Papowitz, collection and analysis, decision to publish, or United Nations Children’s Fund (UNICEF); preparation of the manuscript. Sathyanarayanan Doraiswamy, United Nations High Commissioner for Refugees (UNHCR); Henia References Dakkak, United Nations Population Fund 1. United Nations High Commissioner for Refugees. (UNFPA); Lisa Thomas, World Health 2013 Global Trends. Geneva; 2014 Organization (WHO); Sandra Krause,Women’s 2. Internal Displacement Monitoring Center. Global Refugee Commission (http://iawg.net/steering- Estimates 2013: People displaced by disasters. committee-members/). Geneva; 2014. 3. World Health Organization. Trends in maternal Author Contributions mortality: 1990 to 2010. Geneva; 2013. Conceived and designed the experiments: NTT 4. United Nations Children’s Fund. Levels and Trends in JM SK CH. Performed the experiments: NTT. Child Mortality: Report 2012. New York; 2012. Analyzed the data: AD NTT. Wrote the paper: 5. The Sphere Project. Humanitarian Charter and NTT AD JM SK CH. Minimum Standards in Disaster Response. Geneva; 2000, 2011 revision. Citation 6. Women’s Refugee Commission. MISP for Tran N-T, Dawson A, Meyers J, Krause S, Reproductive Health in Crisis Situations: a Distance Hickling C, Inter-Agency Working Group (IAWG) Learning Module. New York; 2006, 2011 revision. on Reproductive Health in Crisis (2015) 7. Inter-agency Working Group on Reproductive Health Developing Institutional Capacity for in Crises. Inter-agency Field Manual on Reproductive Reproductive Health in Humanitarian Settings: A Health in Humanitarian Settings. Geneva; 1999, Descriptive Study. PLoS ONE 10(9): e0137412. 2010 revision. doi:10.1371/journal. pone.0137412 8. United Nations Population Fund. Interagency Reproductive Health Kits. 5th edition. Geneva; 2010. Editor 9. World Health Organization. Health Cluster Guide—a Vicki Marsh, Centre for Geographic Medicine practical guide for country-level implementation of Research Coast, KENYA the Health Cluster. Geneva; 2009. 145 Tran N-T, Dawson A, Meyers J, Krause S, Hickling C, Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis (2015) Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study. PLoS ONE 10(9): e0137412. doi:10.1371/journal.pone.0137412

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he Inter-agency Working Group (IAWG) on Reproductive Health in Crises was formed in 1995 and has grown into a broad-based network of over 1,800 individual members Trepresenting 450 agencies. The IAWG is a highly collaborative coalition led by a Steering Committee of 18 United Nations agencies, international non-governmental organizations and academic institutions that works to expand and strengthen access to quality reproductive health (RH) services for persons displaced by conflict and natural disasters. Between 2002 and 2004, the IAWG undertook an evaluation of RH for refugees and internally displaced persons (IDPs) in order to determine when and where RH services were provided and to identify gaps and challenges to better target resources and interventions. The findings revealed significant progress since 1995 in raising awareness and advancing RH services for conflict-affected populations, particularly those in stable refugee camps. However, major gaps in many RH components were present, including for gender-based violence, HIV/AIDS and sexually transmitted infections, safe motherhood and family planning, as well as youth-friendly services and services that encouraged male involvement. Furthermore, services for IDPs were found to be severely lacking and little was known about the SRH of populations in acute emergencies.

A decade later, the humanitarian context has changed significantly, and the IAWG has undertaken an updated review to identify services, quantify progress, document gaps and determine future directions for programs, advocacy and funding priorities.

This research was made possible with the generous contributions from the United States Government and the John D. and Catherine T. Mac Arthur Foundation.