Reproductive Health in Conflict: Background and Barriers

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Reproductive Health in Conflict Background and
Barriers
Challenges and Frontiers in the Provision of
Global Reproductive Health Services February 5
2009
Therese McGinn, DrPH Associate Professor Columbia
University Mailman School of Public Health
Director, RAISE Initiative
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RH in conflict is a young field

• Prior to mid-1990s Little activity
• Mid-1990s to 2000 Many accomplishments
• Womens Refugee Commission study shows lack of RH
• ICPD recognizes needs of women in conflict
• Inter-agency Working Group created (IAWG)
• RHRC Consortium formed
• Inter-agency Field Manual developed and used
• Other manuals, guidelines, policies developed
• Research studies carried out
• RH services delivered

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RH in conflict is a young field

• Early 2000s Slower progress
• More RH service projects
• More field studies
• IAWG Global Evaluation, 2002-2004
• Recent years Resurgence
• Regional IAWG initiatives
• Revision of Inter-agency Field Manual
• Increasing interest of new organizations

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Can refugee and IDP women get the RH care they
need and want?

• 1994 No
• 2009 Maybe
• Not enough RH care
• Problems of quality

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RH care not equally available

• RH most likely to be available
• Antenatal care, HIV prevention, basic FP
• For refugees in stable camp settings
• In countries with good health systems
  pre-conflict
• RH least likely to be available
• Comprehensive FP, emergency obstetric care,
  clinical care for GBV, STI/HIV treatment
• For IDPs
• For those in dispersed and unstable settings
• In countries with relatively weak health systems
  pre-conflict

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Countries economic status influences the scope
and quality of RH care provided
Congo, 2007
Afghanistan 2003
Colombia 2007
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Barriers to RH in conflict

• Barriers to providing care
• Demand barriers
• Organizational barriers
• Policy and funding barriers

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Barriers to providing care

• Inadequate number and types of trained staff
• Poor infrastructure
• Weak logistics systems
• Inadequate funding
• Insecurity

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Barriers to demand for RH

• Low pre-existing awareness and use of RH
• Fees
• Societal disapproval of RH
• Low autonomy for women
• ?Opportunity to engage communities

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Organizational barriers to RH in conflict

• RH is new to humanitarian agencies
• Conflict settings are new to development agencies
• By definition, new means
• No skilled staff
• No policy or program guides
• No institutional experience
• Internal systems must adapt

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Organizational barriers to RH

• Humanitarian agencies skilled in emergencies
• May not transition to services needed after
  emergency
• Traditional focus on mortality reduction
• High turnover of some staff
• Short funding cycles

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Organizational barriers to RH

• Data collection low priority
• Limited indicators and detail
• Minimal research
• Not humanitarian agencies usual focus
• RH researchers not experienced in conflict
  settings
• Challenging logistics, security, skilled staff
• Real ethical considerations

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Organizational barriers to RH

• RH is controversial
• Organizations staff, Boards, donors may not
  support RH activities
• Organizations may expect negative response from
  communities
• Organizations may fear politics of RH

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Policy and funding barriers

• Health policies may restrict care
• Are human resources used well?
• Are mid-level providers permitted to do
  procedures?
• Do criteria exclude women from RH care?
• Is husbands or parents consent required?
• Are age or parity restrictions in place?
• Is care linked to reporting, e.g., for GBV?
• Do fees exclude women and the poor?
• Fee-waiver systems shown to be unevenly
  implemented

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Policy and funding barriers

• Exclusion from policy mechanisms
• Refugees often left out of host country and
  multi-national policy and planning
• RH often left out of humanitarian policy and
  planning
• IDPs have no responsible authority, other than
  their governments

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Policy and funding barriers

• Decision-makers not held accountable
• Funding commitments ? Actual contributions
• Approving resolutions ? implementing provisions
• Passing laws ? Implementing laws
• What gets measured gets done
• Accountability follows monitoring

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What are the practical lessons?

• Provide RH services We know what to do
• Apply Best Practices to new settings
• Measure processes and results
• Share findings
• Reduce barriers to demand
• Engage women, men, youth to address concerns
• Recognize that progress is slow at first

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What are the practical lessons?

• Build on organizations strengths
• Collaborate with humanitarian and RH agencies
• Support internal learning
• Document and share internal processes
• Hold decision-makers accountable
• Analyze policies, advocate needed changes
• Monitor What gets measured gets done!

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Dont agonize, Organize!