UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)
|
| UN Population Division, Department of Economic and Social Affairs, with support from the UN Population Fund (UNFPA) |
|
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This document is being made available by the Population Information
Network (POPIN) Gopher of the United Nations Population Division,
Department for Economic and Social Information and Policy Analysis,
in collaboration with the United Nations Population Fund Emergency
Relief Operations. This article will be published in the September
1995 issue of Entre Nous.
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Reproductive Health, Refugees and
Internally Displaced Persons
Place and Role of UNFPA
by
Dr. Daniel Pierotti
Senior Adviser
United Nations Population Fund
Emergency Relief Operations
Geneva, Switzerland
1. At the end of 1994 there were approximately 50 million
refugees and internally displaced persons. This represents 1
individual out of 113 human beings (March 1995).
2. But the most alarming aspect is the spiralling growth of these
populations. These have increased ten-fold since 1974. As a
comparison, the world population for the same period has increased
by 41%.
3. As a result, the international community has constantly been
obliged to multiply its various types of efforts, and to create the
humanitarian organization to cope. Interventions have increased one
hundred-fold over the past 25 years.
4. Most of these populations are living in precarious and fragile
conditions due to violent internal or external conflicts.
Furthermore, almost three quarters of these populations are
estimated to be women and children, which further illustrates the
dramatic nature of the problem.
5. There are 4 phases in refugee situations - Exodus, setting up,
stabilization and return.
6. During the critical phases of exodus and setting up, it is
necessary to take well known and codified urgent measures. During
these two phases there are five main killers to fight urgently:
diarrhoeal diseases, respiratory infections, measles, malnutrition,
malaria (when prevalent) and other potential epidemics.
7. Once the basic needs of safe water, food and sanitary health
measures are provided, other basic preventive and curative services
can be undertaken.8. It must be stressed that there is no
competition or confusion between the acute emergency responses to
survival threats during exodus and the first days in the new
location; and on the other hand, the basic primary health care
measures needed once the population has been sheltered, nourished
and reasonably freed from epidemics.
9. Reproductive health is an essential component of basic primary
health care.
10. Reproductive health is an integrated approach to
gynaecological, obstetric and sexuality issues. Counselling and
clinical services are provided in a framework where all activities
are integrated and interlinked. Under this concept, reproductive
health becomes part of general preventive health services.
11. Reproductive health can give refugees the basic human welfare
and dignity that is their right.
12. The key issues are safe and adequate maternity care, access to
family planning and child spacing, treatment and prevention of
sexually transmitted diseases (including HIV/AIDS), prevention of -
and response to - sexual violence, gynaecological care, and
prevention and treatment of complications arising from unsafe
abortion, prevention of genital mutilation of young girls.
13. The range of reproductive health services required by refugees
are similar to those needed by any other population. Refugees'
needs are likely to be more influenced by trauma. They are more
vulnerable to abuse. Compared to those of other populations, the
reproductive health-care needs of refugees are therefore likely to
be both more urgent and more acute.
14. Reproductive health is not, however, a new science. In the
past, its components were all dealt with separately.
15. Until recently, in refugee situations, with the exception of
prenatal and postnatal care and safe delivery, reproductive health
issues were neglected by primary health care services. Family
planning and birth spacing activities consisted of providing only
minimal measures.
16. In 1994 the situation changed totally. This new approach to
reproductive health became a basic notion widely accepted during
the International Conference on Population in Cairo. For the first
time at such a forum, the issue of refugee reproductive health was
highlighted and taken into account in the final document and Plan
of Action.
17. It is quite clear that the dramatic events in 1994 in the
former Yugoslavia and in Rwanda, with their devastating violence,
mobilized the conscience of the international community to assist
the refugees and internally displaced persons, mostly the
vulnerable groups - women and adolescent girls, who are primarily
affected.
18. In 1994, UNFPA took measures under its mandate to respond to
these dramatic situations. The following main steps have been taken
up to now.
18.1. Firstly, UNFPA's policy concerning emergencies was set up
on My 18, 1994. It consists of recognizing, for refugee and
internally displaced persons, the same vital human rights to
reproductive health as any community not subjected to a disaster
situation.
18.2. UNFPA will focus on providing reproductive health
services, including family .planning, through a framework set up to
answer health needs of these populations.
18.3. Specifically for Rwanda, on June 16 1994, the UNFPA/UNDP
Board of Administrators decided "to assist urgently in an
appropriate way and with the collaboration of other specialized
agencies, the population of Rwanda".
18.4. Fourthly, on November 1, 1994, UNFPA created an Emergency
Relief Operation structure, based in Geneva, in view of specifying
and coordinating appropriate answers to reproductive health needs
of refugees and internally displaced persons.
19. UNFPA is now equipped with the necessary tools to assure that
populations in refugee situations receive appropriate reproductive
health services in a manner similar to that of other populations
who usually benefit from UNFPA programmes.
20. An agreement will be signed at the end of June 1995 between
UNFPA and HCR which will facilitate collaboration on common
activities and maximize inputs of both agencies.
21. What will UNFPA focus on in order to implement its policy?
Refugees and internally displaced persons cannot be considered as
the priority for UNFPA. These are the responsibility of UNHCR
through its mandate. However, UNFPA's mandate specifies
responsibility for reproductive health issues. Refugees and
internally displaced persons should not be neglected in the
framework of UNFPA's mandate, mostly as they are extremely
vulnerable groups living in precarious and fragile conditions..
22. Before 1994, I don't think that UNFPA played a role in refugee
situations. Maybe after the conflict, as a rehabilitation project
for the population on their return. But this type of project could
be assimilated in the regular type of project developed by UNFPA,
for example the rehabilitation project of September 1994 on Rwanda.
23. In February 1995, I sent a simple questionnaire to the UNFPA
network in the field, and to the Directors of the geographic
divisions, to know what they were doing for refugees and internally
displaced persons.
24. I contacted UNFPA CD, CST, Directors. I received responses
from 96%. The answers can be divided into 4 categories:
- no refugees or IDPs (6)
- IDPs or refugees: no UNFPA projects (1 out of 2)
- UNFPA project (1 out of 2).
25. UNFPA projects vary, in type, contents and duration. Sometimes
the input is really marginal, passive with isolated punctual
action: provision of contraceptive supplies (almost exclusively
condoms), workshops, or distribution of family planning information
material in local languages.
26. In some cases, there is no specific earmarked project for
refugees. Instead there is a national programme for host
populations where refugees and IDPs are included. In this case, the
principal course of action is to strengthen the existing structures
and a distribute medical equipment and contraceptive supplies. In
most cases, these projects consist of rehabilitation of a MCH/FP
programme which had ceased due to war or internal conflict.
27. Few projects are specifically developed for refugees or
internally displaced populations. In most cases these are MCH/FP
projects, without implementation of the global concept of
reproductive health. Their budgets come from the UNFPA programme
budget of the host country. As yet in UNFPA, there is no specific
budget for reproductive health projects for refugees and internally
displaced populations. Executing partners belong to host
authorities, NGOs or UN agencies. There are no pre-established
criteria for the choice of a partner. Apparently the main elements
for choice are presence in the field and interest in executing the
project.
28. Among these MCH/FP projects, one is very different in
character. It consists of answering psycho-social needs of
traumatised women by violent events including sexual violence
(Bosnia-Croatia).
29. Projects for refugees are for a short duration - one year or
less - but can be renewed. The budget is modest compared with
projects in non conflict situations.
30. All projects should be elaborated in the framework of UNFPA's
mandate.
31. In most UNFPA projects elaborated for refugees, clinical and
counselling services in family planning, advising and preventing
STD/HIV/AIDS, training the personnel and community self-help are
the elements most often found, but there is not a single project
with a holistic approach.
32. Violence on many occasions has totally blocked implementation
of Reproductive Health activities. This factor must be taken into
account. It also confirms that reproductive health services can
only be developed adequately when the situation is stabilised. At
field level, coordination between reproductive health and family
planning projects or agencies must be assured.
33. In total UNFPA activities in refugee situations may seem
modest. However, before 1994, projects were almost non-existent.
Reproductive health activities during the last year need
improvement, strengthening and some type of standardization.
34. Projects in the pipeline:
- The Girl Guides and Girl Scouts project: developing specific
activities for adolescent girls in camps (WAGGS); - Reproductive
health kit in Bosnia (WHO EURO);
- Psychosocial project for traumatized women (MARIE STOPES
INTERNATIONAL); - Zaire - reproductive health projects for
refugees in Goma and Bukavu (HCR); - IOM project on effects of
conflict on sexual behaviour and outcome of pregnancies (IOM); -
Fiji: preliminary contacts for the refugees in island of
Bougainville (UNFPA).
35. What can be done when refugees/internally displaced persons
are being accommodated?
- Inquire if there is any reproductive health service offered. -
Seek collaboration with UNHCR Health coordinator.
- Facilitate the nomination of a reproductive health
coordinator. - Identify potential partners for execution of
projects. - Facilitate reproductive health needs assessment
- Develop reproductive health activities if there are any
- The following should always be kept in mind:
* No vertical but integrated approach
* Respect for individual choice
* Confidentiality
* Sensitivity to cultural patterns
* Consult women's groups
* Balance clinical/counselling services
* Family planning sensitive issues
* Child spacing or family health if appropriate
* Priority to women and adolescent girls
* Specific global services for women - "the tent for women"
* Look at references system
* Strengthen host health referral and dispensary facilities
* Identify adequate executing partners
* Hire professional from refugee population
* Develop specific services for adolescents
- Contraceptive supplies should be based on:
* past use by types and percentage
* adapted to local situations
* corresponding with training skills
* prepare information leaflets in local languages
- Abortion is a difficult issue but should be dealt with:
* treat complicated abortion
* facilitate safe abortion when legal, and requested by the
woman
* special attention towards victims of sexual violence
* prevent it through contraceptive efforts in pre- and
post-abortion
* Emergency contraception should be considered.
- Prevention of Reproductive Tract Infections including
sexually transmitted diseases and HIV/AIDS, through preventive
counselling, condom distribution and treatment of symptomatic
infections, as part of primary health care.
- Prevention and treatment of infertility and sub-fecundity, as
part of primary health care.
- Routine screening for other female reproductive health
conditions, such as urinary tract infections, cervical infections,
and cervical and breast cancer, when local expertise allows it, and
when potential follow-up exists.
- Special attention should be given to sexual violence where
women are the primary victims.
- Harmful sexual practices such as female genital mutilation
should be discouraged.
36. Before the event arrives, each Country Director should have
prepared as contingency planning a summarized form on the
population to be considered as refugees and those as internally
displaced persons, and transmit it to responsible officers with the
following basic information:
- demographic
- cultural
- use and level of health services
- specific notes on reproductive health
In light of this information, services should, before their
implantation, foresee the following:
- condoms
- home delivery kits
- reproductive health kits
- needs assessment mission
It should always be kept in mind that reproductive health services
should be present as soon as possible and not interfere with
priority measures for survival.
37. The Symposium
In November 1993, a first project was written, the final
version approved one year later jointly by UNFPA and UNHCR. The
objectives were:
- To debate and agree on the basic reproductive health services
to be provided to refugee and IDP populations.
- Prepare a field manual for health coordinators working in
refugee situations.
The Symposium was held on 28-30 June 1995 in Geneva (see separate
Resum‚)
41. Availability for assessment, monitoring and evaluation of
projects.
Conclusion
UNFPA mandate consists of providing reproductive health
services to populations in need, in any circumstances.
In 1995, refugees and internally displaced populations are
close to 50 million.
Actually, in more than half of the countries sheltering
refugees or internally displaced persons with UNFPA presence, there
are no or only fragmented and incomplete reproductive health and
family planning services. This situation is totally unacceptable.
The minimum that country directors are morally and
professionally obliged to accomplish is to inquire about
reproductive health services in refugee situations and take all
necessary action to answer to the reproductive health needs of
these populations wither directly or through associate partners.
UNFPA is confronted with a new challenge: to be sure that all
refugees and internally displaced populations receive reproductive
health and family planning services corresponding to their needs
and that these are adapted to their demands and cultural
sensitivity.
UNFPA, through its dense network of country directors, its
regional country support teams, its inter-regional emergency relief
operations structures, must mobilise its technical and financial
resources. In doing so, through a global and concerted effort,
development and strengthening of reproductive health activities
will become routine and will benefit refugees and internally
displaced populations.
Dr D. Pierotti
UNFPA Emergency Relief Operations
Geneva
31 July 1995