- About HHR
By Rachel Kelley and Charlotte Greenbaum
Reproductive health care funding has captured the American limelight in recent months. Whether responding to health care legislation or nonprofit philanthropies’ funding decisions, advocates across the country have defended the essential role of reproductive health care services to women’s and families’ wellbeing. As these conversations continue in the context of American politics, funding for reproductive health care remains in jeopardy not only in the US, but throughout the world. The need for reproductive health care – especially in situations of armed conflict and natural disaster – far exceeds the availability of these life-saving services. International donors can improve the availability of reproductive health care by funding and collaborating with local organizations “on the ground” in their native countries.
Without renewed commitment and collaborative approaches to the provision of reproductive health (RH) services during humanitarian emergencies, the international community’s disaster response efforts will be rendered increasingly insufficient. The number of disaster-affected people has tripled over the last decade in comparison to previous years, and climate change projections forecast deteriorating conditions as global temperatures continue to rise.1 Not surprisingly, prolonged droughts, more frequent flash floods, and rising sea levels are predicted to displace hundreds of millions of people. One estimate suggests that environmental factors will displace 200 million people by 2050.2 Since environmental migration is likely to continue to be mainly from one region to another within the same country, the population of internally displaced persons (IDPs) is set to increase substantially. As disasters become more frequent, so too does the need for reproductive health services during such emergencies.
Women, children, and other vulnerable populations – those most impacted by reproductive health care access – are least equipped to cope with the effects of disaster and displacement. Lower socioeconomic status, limited access to information, and restrictions on behavior all contribute to the erosion their coping abilities. According to the Intergovernmental Panel on Climate Change, 2007, women “are disproportionately involved in natural resource-dependent activities, such as agriculture, compared to salaried occupations.”3 Thus not only are they statistically more likely than men to die in natural disasters, but they are also more likely to lose their means of livelihood when displaced from land that used to support agricultural or natural-resource-based employment. Assumptions by male-dominated government offices that often direct aid toward male head-of-households further exclude women from recovery resources.4
Without access to resources, needs go unmet. Unmet reproductive health needs in particular contribute significantly to displaced persons’ mortality and morbidity. A survey conducted by the Institute for Justice and Democracy in Haiti eight months after the 2010 earthquake in Haiti found that 33% of families living in displaced persons’ camps reported vaginal and reproductive problems, including pregnancy complications, and 13% of families were aware of someone getting sexually assaulted or threatened in their camp, a statistic which is likely underreported.5 With the breakdown of social, political, and economic security structures, disasters put women at heightened risk for sexual and gender-based violence, human trafficking, and survival sex or other high-risk behaviors.
In such situations, just when risks to reproductive health (and consequently, to human lives) are increasing, many actors are inclined to forgo support for reproductive health services. Reproductive health services, already subject to the fickleness of local and international politics, are too often regarded as a lesser priority or an impractical undertaking in humanitarian emergencies. Tellingly, a comparison of low-income countries found that conflict-affected countries received 53.3% less official development assistance for reproductive health than non-conflict-affected countries despite experiencing greater need for RH services.6 Aside from funding limitations, humanitarian actors themselves may impede implementation of the complete set of minimum services set out by international standards. This mindset persists, in part, due to the pervasive false dichotomy constructed between relief and development efforts. It is true that providing quality reproductive health care is a challenging task, but instead of collaborating with partners to eliminate service gaps and parallel systems, humanitarian actors often find themselves competing for limited funding and even giving up reproductive health services entirely. Such misaligned funding incentives allow short-sighted, disjointed relief efforts to continue instead of fostering long-term collaborative plans for the comprehensive health systems necessary to sustainable recovery.
Fortunately, paradigms of collaboration are growing increasingly more common in the provision of RH services. Growing implementation of the Minimal Initial Service Package (MISP) for reproductive health is an illustrative example. First outlined in the 1996 Interagency Field Manual for Reproductive Health in Refugee Situations (under the coordinating leadership of the Interagency Working Group on Reproductive Health in Crises – IAWG), the MISP details international standards of practice for the provision of reproductive health services at the onset of humanitarian crises. Coordination is prominent among eight fundamental principles of MISP implementation discussed in the 2010 Inter-agency Field Manual on Reproductive Health in Humanitarian Settings. The MISP calls for coordination between official bodies (host country government, UN agencies, NGOs), between sectors and disaster response clusters, across levels of service providers (community health workers, traditional midwives, doctors, nurses), and across levels of care (community health outreach, clinics, hospitals).
In the aftermath of the 2010 earthquake in Haiti, the MISP assessment conducted by CARE, International Planned Parenthood Federation, Save the Children, and Women’s Refugee Commission found “an unprecedented level of awareness among international organizations about the need for priority RH services and stronger efforts to address them.” However, the vast majority of MISP was implemented by international organizations with limited consultation of local groups. The report recognized “a missed opportunity for international organizations to identify and support local capacity in the RH responsiveness.” This was partially attributed to local NGOs’ difficulty attending coordinating meetings, which were hosted at the restricted-access UN Logbase.7 The awareness of this missed opportunity to strengthen and expand local RH capacity should be considered promising, however, insofar as it implies a commitment to seize these opportunities in the future.
Among the opportunities missed when disaster response efforts fail to engage local RH capacity is the opportunity to improve the timeliness of RH care delivery. Local organizations’ grassroots connections to their communities precede crises and the arrival of international assistance, which gives them a unique first responder role when disaster strikes. Analyses of the humanitarian responses to two of the most devastating natural disasters in recent history – the 2010 earthquake in Haiti and floods in Pakistan – have noted the immediate and critical role played by local communities.7,8 Reproductive health concerns, whether the threat of gender-based violence or the urgency of a high-risk pregnancy, cannot wait while international actors who are less familiar with local contexts to orient themselves. Thus an effective disaster response by international actors should invest in the established connections and contextual understanding of local networks.
Failing to collaborate with local organizations is also a missed opportunity to improve cultural competency of RH care. Cultural competency is essential in all health services, but it is of particular importance in the field of reproductive health, which presents strong sensitivities due to its relation to sexual practices. Failure to address reproductive health in a manner acceptable to host communities may thwart future efforts to improve reproductive health. Local organizations hold a cultural understanding and position in the community that diminishes this risk, often meaning that they are the entities best suited to address reproductive health issues. A promising example of the power of local organizations is the Reproductive Health Group, a Guinean organization of Liberian and Sierra Leonean refugee midwives and laywomen that was profiled in a 2010 article in Disasters. This organization worked as a part of the Guinean health system, helping to make the RH services in their region “the most effective in Guinea at the time.” A WHO consultant characterized the group’s work as “the ideal situation whereby refugees participate in their own health care and in this instance it may well represent ‘best practice’ worth of intensive study for possible replication in other settings.”9 Of course, no organization is perfect; local organizations will have certain political or social barriers within the community they serve, but their cultural and sociopolitical position gives them agency that international organizations can only approximate. Thus, local organizations must be considered essential partners in the implementation of the MISP and all other RH programs.
In addition to strengthening cultural competencies, local organizations improve quality of reproductive health care by fostering community support networks. Since organizations’ staff and leadership are also community members, they can create collaborative environments that draw in community services that may be less accessible to visitors (religious or cultural institutions, for example). Quality RH services are particularly dependent on such collaborative environments; reproductive health concerns have substantive psychological and social implications that many other health concerns do not have to confront. For example, an antibiotic prescription does not implicate societal gender roles and women’s political or economic empowerment as directly as a contraceptive. Facilitating the recovery of a rape survivor requires a whole network of social support; whereas the recovery of an acute injury may only need a few weeks of rest or focused rehabilitation.
A recent study by the Neonatal Mortality Formative Research Working Group attests to this concept of creating a community network for RH care, as it relates to childbirth: “Interventions cannot be entirely facility-based…They must address community norms and involve the main gatekeepers, particularly traditional birth attendants, grandmothers, and family members who attend the delivery, as they are usually the mother’s main source of advice.”10 The provision of RH services by the local community – as opposed to outside organizations operating in isolation – integrates reproductive health care into the community. It demonstrates to community members that their own community values reproductive health and facilitates the involvement of community members like midwives and grandmothers who may have otherwise remained outside of the formal network of RH service providers.
In theory and in practice, investment in local organizations’ capacity to provide reproductive health care is necessary to secure the present and future wellbeing of disaster-affected communities worldwide. At a time when populations and natural disasters are increasing, reproductive health care is becoming an ever more urgent need to which both international and local leaders must respond. Integrating RH services and local organizations into the disaster response paradigm demands increased awareness, commitment to collaboration, and new systems of coordination. This will not happen without a commitment of substantive human and financial resources.
Although such resources remain stretched, the global community is making encouraging progress through its increasing implementation of MISP and affirmation of local coordination and capacity building. It is true that many local organizations are not equipped to provide services at the scale of programs implemented by many international organizations. However, the increased financial and technical support afforded by disaster response scenarios provides valuable opportunities for capacity-building and organizational strengthening, especially in the often underdeveloped field of reproductive health care. As the rhetoric surrounding the response to the 2010 earthquake in Haiti reminds us, disasters afford the opportunity to “build back better.” Included in this are not only physical structures, but also the structures of organizations and the relationships between them. An organized, collaborative disaster response that includes and supports local capacity can lay the foundation for enduring reproductive health care systems. Then as relief efforts subside after disaster, they leave behind a robust network of local organizations better equipped to respond to their communities’ needs.
As the crisis in the Horn of Africa persists and communities worldwide continue coping with disasters that have long since left the news, international relief efforts should not miss this opportunity. Collaboration with local organizations during emergencies will improve the timeliness, cultural sensitivity and community integration of reproductive health care. It will also give affected populations the decision-making role in their lives that is their right. Reproductive health care saves lives, and it will save even more lives as the international humanitarian community recognizes that local communities are humanitarians, too.
Rachel Kelley and Charlotte Greenbaum are studying Human Biology at Stanford University. They wrote the following piece while working as interns for the Astarte Project at the JSI Research & Training Institute in Washington, DC.
Photo: By Ceridwen (Own work) [CC-BY-SA-2.0-fr (http://creativecommons.org/licenses/by-sa/2.0/fr/deed.en)], via Wikimedia Commons
1. Integrated Regional Information Networks. “Disaster Reduction and the Human Cost of Disaster,” IRIN (2005). Available here.
2. N. Stern (2006) “Part 11: Impacts of Climate Change on Growth and Development’. “Part II: Impacts of Climate Change on Growth and Development,” The Economics of Climate Change: the Stern Review (Cambridge, MA: Cambridge University Press 2006).
3. United Nations Population Fund, State of the World Population 2009 (Geneva: UNFPA, 2009).
4. United Nations Population Fund, State of the World Population 2009 (Geneva: UNFPA, 2009).
5. Institute for Justice and Democracy in Haiti. “‘We’ve Been Forgotten’ Conditions in Haiti’s Displacement Camps Eight Months After the Earthquake,” Institute for Justice and Democracy in Haiti (September 2010). Available here.
6. P. Patel et al. “Tracking Official Development Assistance for Reproductive Health in Conflict-Affected Countries,” PLoS Medicine 6/6 (2009), pp. 1-13.
7. S. Krause et al. “Priority Reproductive Health Activities in Haiti: An inter-agency MISP assessment conducted by CARE, International Planned Parenthood Federation, Save the Children and Women’s Refugee Commission.” Women’s Refugee Comission (2010). Available here.
8. R. Polastro et al. “Inter-Agency Real Time Evaluation of the Humanitarian Response to Pakistan’s 2010 Flood crisis,” DARA (March 2011). Available here.
9. A. Von Roenne et al. “Reproductive health services for refugees by refugees: an example from Guinea” Disasters 34/1 (2010): pp. 16-29.
10. Neonatal Mortality Formative Research Working Group. “Developing community-based intervention strategies to save newborn lives: lessons learned from formative research in five countries,” Journal of Perinatology 28 (2008), S2–S8.
Papers in Press
Medical Students Attitudes toward Torture, Revisted
Krista Dubin, Andrew R. Milewski, Joseph Shin, and Thomas P. Kalman
The Cholera Epidemic in Zimbabwe, 2008-2009; A Review and Critique of the Evidence
C. Nicholas Cuneo, Richard Sollom, and Chris Beyrer
HIV Criminalization Laws and the Right to Health
Canada’s Mining Industry in Guatemala and the Right to Health of Indigenous Peoples