Miimum Iitial Service Package 11 This Chapter describes a series of actios eeded to respod to the reproductive health (RH) eeds of populatios i the early phase of a refugee situatio (which may or may ot be a emergecy). The Miimum Iitial Service Package (MISP) ca be implemeted without ay ew eeds assessmet sice documeted evidece already justifies its use. The MISP is ot just kits of equipmet ad supplies; it is a set of activities that must be implemeted i a coordiated maer by appropriately traied staff. 2CHAPTER TWO Miimum Iitial Service Package (MISP) Cotets: Objectives of the MISP Compoets of the MISP 4 Idetify a orgaisatio(s) ad idividual(s) to facilitate the coordiatio ad implemetatio of the MISP 4 Prevet ad Maage the Cosequeces of Sexual Violece 4 Reduce HIV Trasmissio 4 Prevet excess eoatal ad materal morbidity ad mortality 4 Pla for the provisio of comprehesive RH services, itegrated ito Primary Health Care, as soo as possible Broad Terms of Referece for a RH Coordiator/Focal Poit Material Resources Moitorig ad Surveillace Special Note: a The reader must refer to the relevat chapters i the Maual to properly implemet the MISP.
12 Miimum Iitial Service Package (MISP) The major killers i refugee emergecies diarrhoea, measles, acute respiratory ifectios (ARI), malutritio ad malaria, where prevalet are well documeted. Resources should ot be diverted from dealig with these problems. However, there are some aspects of reproductive health that also must be addressed i this iitial phase to reduce mortality ad morbidity, particularly amog wome. Please remember that the compoets of MISP form a miimum requiremet. The expectatio is that the comprehesive services as outlied i the rest of this Field Maual will be provided as soo as the situatio allows. Objectives of the MISP: IDENTIFY a orgaisatio(s) ad idividual(s) to facilitate the coordiatio ad implemetatio of the MISP; PREVENT ad maage the cosequeces of sexual violece; REDUCE HIV trasmissio by 4 eforcig respect for uiversal precautios agaist HIV/AIDS ad 4 guarateeig the availability of free codoms; PREVENT excess eoatal ad materal morbidity ad mortality by 4 providig clea delivery kits for use by mothers or birth attedats to promote clea home deliveries, 4 providig midwife delivery kits (UNICEF or equivalet) to facilitate clea ad safe deliveries at the health facility, ad 4 iitiate the establishmet of a referral system to maage obstetric emergecies; ad PLAN for the provisio of comprehesive RH services, itegrated ito Primary Health Care (PHC), as the situatio permits Compoets of the MISP Idetify a Orgaisatio(s) ad Idividual(s) to Facilitate the Coordiatio ad Implemetatio of the MISP A qualified ad experieced perso should be idetified to coordiate RH activities at the start of the emergecy respose. The overall leadig agecy should be resposible for the desigatio of such a perso, ad the perso appoited should work uder the supervisio of the overall Health Coordiator. RH focal poits should be desigated withi each camp, ad withi each implemetig agecy. These health professioals, experieced i reproductive health, should be i post for a miimum of six moths, as it is likely to take this log to establish comprehesive RH services. All relief orgaisatios should, i accordace with their madates, ad withi the framework of emergecy preparedess ad respose, trai ad sesitise their staff o RH issues ad geder awareess. (See Terms of Referece for the RH Coordiator at the ed of this chapter.) Prevet ad Maage the Cosequeces of Sexual Violece Sexual violece is strogly associated with situatios of forced populatio movemet. I this cotext, it is vital that all actors i the emergecy respose are aware of this issue ad prevetive measures are put i place. The UNHCR Guidelies for Prevetio ad Respose to Sexual Violece agaist Refugees (1995) should be adhered to i the emergecy respose. Measures for assistig refugees who have experieced sexual violece, icludig rape, must also be established i the early phase of a emergecy.
Miimum Iitial Service Package 13 Wome who have experieced sexual violece should be referred to the health services as soo as possible after the icidet. Protectio staff should also be ivolved i providig protectio ad legal support to survivors of sexual violece. Key actios to be take durig the emergecy to reduce the risk of sexual violece ad respod to survivors are: desig ad locate refugee camps, i cosultatio with refugees, to ehace physical security esure the presece of female protectio ad health staff ad iterpreters iclude the issues of sexual violece i the health coordiatio meetigs esure refugees are iformed of the availability of services for survivors of sexual violece provide a medical respose to survivors of sexual violece, icludig emergecy cotraceptio, as appropriate idetify idividual or groups who may be particularly at risk to sexual violece (sigle female heads-of-households, uaccompaied miors, etc.) ad address their protectio ad assistace eeds. See Chapter Four for further iformatio o elemets of prevetio ad respose to sexual violece. Reduce HIV Trasmissio Eforce Respect for Uiversal Precautios Agaist HIV/AIDS Uiversal precautios agaist the spread of HIV/AIDS withi the health care settig must be emphasised durig the first meetig of Health Coordiators. Uder the pressure of a emergecy situatio, it is possible that field staff are tempted to take short cuts i procedures which ca jeopardise the safety of patiets ad staff. It is essetial that uiversal precautios be respected. (See Chapter Five for details o uiversal precautios.) Guaratee the Availability of Free Codoms Availability of codoms should be esured from the begiig so that they ca be provided to ayoe who requests them. Sufficiet supplies should be ordered immediately. (See Aex 3, Chapter Five, Prevetio ad Care of Sexually Trasmitted Diseases icludig HIV ad AIDS for calculatig codom supplies.) As well as providig codoms o request, field staff should make sure that refugees are aware that codoms are available ad where they ca be obtaied. Codoms should be made available i health facilities especially whe treatig cases of STDs. Other distributio poits should be established so that those requestig codoms ca obtai them i privacy. Prevet Excess Neoatal ad Materal Morbidity ad Mortality Provide Clea Delivery Kits for Use by Mothers or Birth Attedats to Promote Clea Home Deliveries A refugee populatio will iclude wome who are i the later stages of pregacy, ad who will therefore deliver withi the iitial phase. Simple delivery kits for home use should be made available for wome i the late stages of pregacy. These are very simple kits that the wome, themselves, or traditioal birth attedats (TBAs) ca use. They ca be made up o site ad iclude: oe sheet of plastic, two pieces of strig, oe clea razor blade ad oe bar of soap. UNFPA also supplies this kit. A formula, based upo the Crude Birth Rate (CBR), is used to calculate the supplies ad services required. With a CBR of three to five per cet per year, there would be some 75-125 births i a three-moth period i a populatio of 10,000. From this, a calculatio ca be made as to how may kits should be ordered. Provide Midwife Delivery Kits (UNICEF or equivalet) to Facilitate Clea ad Safe Deliveries at the Health Facility I the early phase of a emergecy, births will ofte take place outside the health facility with- CHAPTER TWO
14 out the assistace of traied health persoel. Approximately 15 per cet of births will ivolve some complicatios. Complicated births should be referred to the health cetre. The supplemetary uit of the New Emergecy Health Kit 98 (NEHK-98) has all the materials eeded to esure safe ad clea ormal deliveries. May obstetric emergecies ca be maaged with the equipmet, supplies ad drugs cotaied i the NEHK-98. Obstetric complicatios that caot be maaged at the health cetre should be stabilised before trasfer to the referral hospital. Iitiate the Establishmet of a Referral System to Maage Obstetric Emergecies Approximately three to seve per cet of deliveries will require Caesarea sectio. Additioal obstetric emergecies may eed to be referred to a hospital that is capable of performig comprehesive essetial emergecy obstetric care. (Refer to Chapters Three ad Seve for iformatio o pregacy ad delivery complicatios.) As soo as the situatio permits, a referral system that maages obstetric complicatios must be available for use by the refugee populatio 24 hours a day. Where feasible, a host-coutry referral facility should be used ad supported to meet the eeds of refugees. If this is ot feasible because of distace or the iability of the hostcoutry facility to meet the icreased demad, the a appropriate refugee-specific referral facility should be provided. I either case, it will be ecessary to coordiate with host-coutry authorities cocerig the policies, procedures ad practices to be followed withi the referral facility. The protocols of the host coutry should be followed, although some variatio may have to be egotiated. Be sure there is sufficiet trasport, qualified staff ad materials to cope with the extra demads. Pla for the Provisio of Comprehesive RH Services, Itegrated Ito Primary Health Care, as Soo as Possible It is essetial to pla for the itegratio of RH activities ito primary health care durig the iitial phase. If ot, the provisio of these services may be delayed uecessarily. Whe plaig, it is importat to iclude the followig activities: The collectio of backgroud iformatio o materal, ifat ad child mortality, available HIV/STD prevalece ad cotraceptive prevalece rates (CPR). This iformatio ca be obtaied from the refugees coutry of origi from such sources as WHO, UNFPA, the World Bak ad Demographic ad Health Survey (DHS). Gatherig this iformatio could be the resposibility of the Headquarters of implemetig agecies who may have ready access to these data. The idetificatio of suitable sites for the future delivery of comprehesive RH services (as described i the remaider of this Field Maual). It is importat to address the followig factors whe selectig suitable sites: 4 security both at the poit of use ad while movig betwee home ad the service delivery poit 4 accessibility for all potetial users 4 privacy ad cofidetiality durig cosultatios 4 easy access to water ad saitatio facilities 4 appropriate space 4 aseptic coditios A assessmet of the capacity of staff to udertake comprehesive RH services should be made ad plas put i place to trai/retrai staff. Equipmet ad supplies for comprehesive RH services should be ordered. This will allow comprehesive services to begi as soo as the situatio stabilises.
Miimum Iitial Service Package 15 CHAPTER TWO Broad Terms of Referece for a RH Coordiator/ Focal Poit Uder the auspices of the overall health coordiatio framework, the RH Coordiator/Focal Poit should a be the focal poit for RH services ad provide techical advice ad assistace o reproductive health to refugees ad all orgaisatios workig i health ad other sectors as eeded. a liaise with atioal ad regioal authorities of the host coutry whe plaig ad implemetig RH activities i refugee camps ad amog the surroudig populatio, where appropriate. a liaise with other sectors (protectio, commuity services, camp maagemet, educatio, etc.) to esure a multi-sectoral approach to reproductive health. a create/adapt ad itroduce stadardised strategies for reproductive health which are fully itegrated withi PHC. a iitiate ad coordiate various audiece-specific traiig sessios o reproductive health (for audieces such as health workers, commuity services officers, the refugee populatio, security persoel, etc.). a itroduce stadardised protocols for selected areas (such as sydromic case maagemet of STDs, referral of obstetric emergecies, medical respose to survivors of sexual violece, cousellig ad family plaig services, etc.). a develop/adapt ad itroduce simple forms for moitorig RH activities durig the emergecy phase that ca become more comprehesive oce the programme is cosolidated. a report regularly to the health coordiatio team. Material Resources New Emergecy Health Kit 98 (NEHK-98) The revised NEHK-98 (for 10,000 people for three moths) cotais the followig supplies to implemet the MISP: What is i the NEHK-98 to implemet the MISP Materials for uiversal precautios for ifectio cotrol Equipmet, supplies ad drugs for deliveries at health cetres Equipmet, supplies ad drugs for some obstetric emergecies Equipmet, supplies ad drugs for post-rape maagemet
16 A booklet-describig the NEHK-98 ad how it ca be ordered is available from WHO. Reproductive Health Kit A RH Kit for Emergecy Situatios has bee developed by UNFPA, i cooperatio with others, for use i refugee situatios. It complemets the NEHK-98 ad should be ordered as eeded to lauch the MISP ad support the referral system. The RH Kit is made up of 12 sub-kits, which ca be ordered separately. Materials ad supplies i Subkits 3 ad 6 are already available i the NEHK-98. To order RH sub-kits from UNFPA, cotact the UNFPA Coutry Director i the coutry of asylum, the UNFPA Emergecy Relief Office i Geeva or the UNFPA Procuremet Office i New York. The RH Kit is targeted for use i the iitial acute phase of the emergecy. Oce the situatio stabilises, procuremet of RH materials ad supplies should be doe alog with other health programme supply ad drug orderig. What is i the UNFPA RH Kit For use at primary health care/health cetre level: 10,000 populatio for three moths 0 Traiig ad Admiistratio 1 Codoms 2 Clea delivery sets 3 Post-rape maagemet 4 Oral ad ijectable cotraceptives 5 STD Drugs For use at health cetre or referral level: 30,000 populatio for three moths 6 Professioal midwifery delivery kit 7 IUD isertio 8 Maagemet of the complicatios 8 of usafe abortio 9 Suture of cervical ad vagial 8 tears 10 Vacuum extractio For use at the referral level: 150,000 populatio for three moths 11 A Referral-Level Surgical 11 (reusable equipmet) 11 B Referral-Level Surgical 11 (cosumable items ad drugs) 12 Trasfusio (HIV testig for blood 11 trasfusio) A booklet describig the RH Kit ad how it ca be ordered is available from UNFPA. (See Appedix Four for cotact addresses.)
Miimum Iitial Service Package 17 Moitorig ad Surveillace CHAPTER TWO Durig the early phase of the emergecy, a limited amout of data should be collected to assess the implemetatio of the MISP. Iformatio o mortality ad morbidity by age ad sex should be routiely collected durig the early phase of a emergecy. Refer to Chapter Nie for more iformatio o these idicators. Cosider selectig MISP idicators from the followig list. MISP Idicators a Icidece of sexual violece: Moitor the umber of cases of sexual violece reported to health services, protectio ad security officers. a Supplies for uiversal precautios: Moitor the availability of supplies for uiversal precautios, such as gloves, protective clothig ad disposal of sharp objects. a Estimate of codom coverage: Calculate the umber of codoms available for distributio to the populatio. a Estimate of coverage of clea delivery kits: Calculate the umber of clea delivery kits available to cover the estimated births i a give period of time.
18 Checklist for the RH MISP a Collect or estimate basic demographic iformatio Total populatio Number of wome of reproductive age Number of me of reproductive age Crude birth rate Age-specific mortality rate Sex-specific mortality rate Number of pregat wome Number of lactatig wome a Prevet ad maage the cosequeces of sexual ad geder-based violece Systems to prevet sexual violece are i place Health service able to maage cases of sexual violece Staff traied (retraied) i prevetio ad respose systems for cases of sexual violece a Prevet HIV trasmissio Materials i place for adequate practice of uiversal precautios Codoms procured ad distributed Health workers traied/retraied i practice of uiversal precautios a Prevet excess eoatal ad materal morbidity ad mortality Clea delivery kits available ad distributed UNICEF midwife kits (or equivalet) available at the health cetre Staff competecy assessed ad retraiig udertake Referral system for obstetric emergecies fuctioig a Pla for the provisio of comprehesive RH services Basic iformatio collected (mortality, HIV prevalece, CPR) Sites idetified for future delivery of comprehesive RH services a Idetify a orgaisatio(s) ad idividual(s) to facilitate the MISP Overall RH Coordiator i place ad fuctioig uder the health coordiatio team RH focal poits i camps ad implemetig agecies i place Staff traied ad sesitised o techical, cultural, ethical, religious ad legal aspects of RH ad geder awareess Materials for the implemetatio of the MISP available ad used