UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)
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| 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
Population Fund Emergency Relief Operations.
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PROCEEDINGS OF THE INTER-AGENCY
SYMPOSIUM ON REPRODUCTIVE HEALTH
IN REFUGEE SITUATIONS
Palais des Nations, Geneva
28-30 June, 1995
=================================================================
CONTENTS
1. INTRODUCTION 1
2. SUMMARY OF GENERAL PROCEEDINGS 4
2.1 Opening Remarks 4
2.2 Proceedings of the Technical Discussions 6
2.3 Main Conclusions and Recommendations 6
2.4 Concluding Remarks 7
3. SUMMARY OF PANEL DISCUSSIONS 9
3.1 First Panel Discussion: 9
"Making reproductive health activities
a reality in refugee situations"
3.2 Second Panel Discussion: 12
"Legal, ethical and human rights issues
on reproductive health in refugee situations"
4. SUMMARY OF WORKING GROUPS PRESENTATIONS 15
4.1 Group 1 Integration of reproductive health into
existing programmes for refugees 15
4.2 Group 2 Community participation 15
4.3 Group 3 Minimum Initial Service Package 16
4.4 Group 4 Information, education and communication 17
4.5 Group 5 Human resources for reproductive health
and training 17
4.6 Group 6 Review of draft Field Manual 18
4.7 Group 7 Ad Hoc Working Group on Implementation 19
5. MAIN CONCLUSIONS AND RECOMMENDATIONS 20
=================================================================
ANNEXES 25
I. Report of Working Group 1 (Integration) 25
II. Report of Working Group 2 (Community Participation) 28
III. Report of Working Group 3 (MISP) 37
IV. Report of Working Group 4 (IEC) 43
V. Report of Working Group 5 (Human Resources) 47
VI. Report of Working Group 6 (Draft Field Manual) 50
VII. Report of the Ad Hoc Working Group on Implementation 52
VIII. Agenda for the Symposium 54
IX. List of participants 56
=================================================================
INTRODUCTION
1.1 PREPARATORY PROCESS
The issue of reproductive health for all, including refugees
and the displaced, was highlighted at the 1994 International
Conference on Population and Development (ICPD): "Migrants and
displaced persons in many parts of the world have limited access
to reproductive health care and may face specific serious threats
to their reproductive health and rights. Services must be
sensitive particularly to the needs of individual women and
adolescents and responsive to their often powerless situation,
with particular attention to those who are victims of sexual
violence." (Plan of Action, ICPD, 7.11)
Today, the number of persons of concern to the Office of the
United Nations High Commissioner for Refugees lies at 23 million
(excluding returnees). There are also an estimated 26 million
internally displaced persons. While the provision of food, clean
water, shelter, sanitation and primary health care are principal
concerns in any refugee emergency, reproductive health care is
also crucial for the physical, mental and social well-being of
any individual. Yet many refugees today have limited access to
adequate reproductive health services. In light of this, UNHCR,
UNFPA and a number of other organizations have responded with a
common objective to promote the introduction or strengthening of
appropriate reproductive health activities in refugee (and
refugee-like) situations.
Recognizing the importance of cooperation and coordinated
responses between the international donor community, governments,
UN agencies and NGOs to achieve this objective, an Inter-Agency
Symposium on Reproductive Health in Refugee Situations was
organized by UNHCR and UNFPA, in collaboration with UNICEF, WHO
and some 50 different organizations.
First Preparatory Meeting, 14-15 December 1994
The first preparatory meeting to the Symposium was held in
Geneva. Participants were able to obtain clear inter-agency
consensus on the overall objective of the initiative.
Participants also agreed that one of the means to meet this
objective was through the creation of a practical tool in the
form of a Field Manual. Working groups were created and would
prepare "technical chapters" on each of the elements identified
by the participants as key to an effective reproductive health
programme in any refugee setting. These elements would involve
safe motherhood, prevention and control of STDs including
HIV/AIDS, prevention and control of sexual and gender-based
violence, family planning, prevention and care of unsafe abortion
and Female Genital Mutilation. It was also decided at this
meeting that a survey of existing reproductive health services in
the field would be conducted and a "framework" for action
prepared for analysis at the next preparatory meeting.
Second Preparatory Meeting, 5-6 April 1995
At the second preparatory meeting held at WHO Headquarters
in Geneva, a framework for the implementation of reproductive
health activities was presented at the same time as the results
of the survey carried out in UNHCR and UNFPA Offices in the
field. This allowed to identify a number of challenges and
limitations which would have to be confronted in making
reproductive health care available in refugee situations, such as
follows:
- the low status of priority given to the delivery of
reproductive health care services in refugee situations,
translated as a limited number of projects;
- the insufficient number of staff in the field qualified to
implement reproductive health services;
- the absence of long-term planning owing to limited funding
and resources and no coordination between agencies and NGOs in
the field;
- the almost inexistant development of comprehensive services.
Often, reproductive health services are limited to clinical
Maternal and Child Health care, family planning being restricted
to ad-hoc distribution of condoms, and prevention and detection
of STDs.
The second preparatory meeting also served to review the
"technical chapters" for the Field Manual as prepared by resource
persons, in order to make them more "practical". It was agreed
that the target audience of the manual would be professionals in
the field who would have to coordinate and would be responsible
for the planning and supervision of the implementation,
monitoring and evaluation of reproductive health services. The
Field Manual would not replace already existing resources but
serve as a complement. At the end of the meeting participants
also agreed that new "technical chapters" would be prepared in
light of the discussions and submitted to a "field" review in
Nairobi.
Nairobi Field Meeting, 10-11 May 1995
Forty representatives of NGOs, UNFPA, UNHCR, UNICEF and
WHO from the field reviewed the documentation as prepared
following the Second Preparatory Meeting to ensure that the
circumstances and needs in the field were fully considered.
Participants unanimously supported the initiative both to address
more comprehensively reproductive health needs in refugee
situations and to create a field manual to assist in coordinating
and planning reproductive health activities. Participants made a
number of recommendations on how to make each "technical chapter"
more practical and useful for the field. They also stressed the
need to address "cross-cutting" issues such as community
participation, IEC, coordination and integration, all of which
are crucial for the implementation of appropriate reproductive
health activities in refugee situations. (A summary of the
proceedings of the Nairobi meeting are available upon request
from the Secretariat of the Symposium).
1.2 THE INTER-AGENCY SYMPOSIUM
Following the above complex preparatory process, some 135
participants attended the Symposium held from 28 to 30 of June
1995 at the Palais des Nations (see Annex IX for the list of
participants). The purpose of the Symposium, as evidenced by its
agenda (Annex VIII), was to address in greater depth some of the
constraints and challenges to promoting the implementation of
reproductive health services in refugee situations.
This was achieved firstly through two panel discussions. The
first of the panels dealt with the implementation of services. A
framework for implementation was presented and the difficulties
and limitations to implementation in the field explored. The
second panel focused on some of the real problems faced in the
field on a daily basis - problems regarding violence, HIV
testing, access to basic services, abortion, etc. - and the
legal, ethical and human rights issues involved in each case.
Secondly, participants reviewed the draft "Field Manual", in
particular the "cross-cutting issues" identified in Nairobi, to
ensure that these were fully and consistently integrated in all
technical chapters and to make certain that the manual be a
practical tool.
Finally, follow-up activities for implementation were
defined. These will involve:
- finalizing (by the end of 1995) and operationalizing the
Field Manual, with field testing over two years and
producing a revised version;
- creating an Inter-Agency Working Group (see Chapter 5 below)
to follow-up closely and facilitate the realization of the
overall objective of promoting the implementation of
reproductive health activities in refugee (and refugee-like)
situations;
- continuing advocacy, in particular to secure funding for
implementation.
The general proceedings of the Symposium and the key points
discussed are summarized in the following chapter.
=================================================================
2. SUMMARY OF GENERAL PROCEEDINGS
2.1 OPENING REMARKS
As Chairperson, Dr. Nafis Sadik, Executive Director of
UNFPA, convened the Symposium by welcoming all the participants
and proposing that the tentative agenda be adopted (see Annex
VIII for agenda). She expressed her pleasure at the strong
commitment to making reproductive health care in refugee
situations a reality evidenced by the presence of a great many
organizations.
The Chairperson then recalled some of the basic points to be
taken into consideration. Refugee women and girls were at
special risk of violence and sexual abuse. The ICPD Programme of
Action put reproductive health, including family planning and
sexual health, firmly in the context of primary health care, and
defined good health as including good sexual and reproductive
health.
There was no competition between immediate responses to
ensure survival and meeting the needs for reproductive health
services as part of primary health care once the basic
requirements of food, shelter and epidemic prevention had been
met.
Dr. Sadik then outlined UNFPA policy and principles on
refugees and internally displaced persons, emphasizing the
present initiative and UNFPA's commitment to the task.
Dr. Sadik then gave the floor to Dr. Hu Ching-Li, Assistant
Director-General of WHO, followed by Dr. Christian Voumard,
Senior Advisor on Health for UNICEF, and Mr. Gerald Walzer,
Deputy High Commissioner, UNHCR. Each explained the special role
their organizations played in addressing reproductive health in
emergency and stable refugee situations and pledged their
commitment to securing this form of health care for persons in
exile.
Dr. Hu Ching-Li, on behalf of WHO Director-General, recalled
that reproductive health and reproductive rights were inalienable
human rights for all peoples, of all nations and of all
generations. He then stressed that reproductive health is central
to human development. Recognizing that women and particularly
refugee women, are biologically and socially more vulnerable than
men, Dr. Hu challenged the participants to the symposium to find
solutions to the many social, logistic, infrastucture, political
and managerial constraints inherent to reproductive health
activities.
Dr. Voumard reaffirmed UNICEF's commitment to the
protection, health and development to populations in emergencies,
refugees and internally displaced persons. He also mentioned
that women bear a disproportionate burden of the consequences of
conflicts. UNICEF has multiplied its interventions in
emergencies and is developing special kits and packages to meet
the basic needs of women in emergencies and for TBAs and
midwifes.
Dr.Voumard concluded saying that reproductive health must be
incorporated in the training programs for the staff and that
reproductive health should be more systematically considered in
rehabilitation and development projects.
Mr. Gerald Walzer concluded the opening remarks of the UN
Agencies. He described today's refugee situation and mentioned
that some 27 million persons are of concern to UNHCR at the end
of 1994. He then recalled the results of the survey undertaken
by UNHCR and which revealed that reproductive health services are
at least inadequate and too often inexistant in a large number of
refugee situations. As refugee situation have proved to increase
the risks of sexual violence, with the HIV/AIDS pandemic which
does not spare the refugees and the often registered high birth-
rates, there is a also need to design appropriate reproductive
health strategies and activities. Refugee participation in the
design and implementation of the strategies will be strongly
recommended. Mr.Walzer concluded by emphasizing how encouraging
it was to see so many agencies participating actively in the
process and this also would be a key for success.
These remarks were followed by two statements from NGO
representatives, Dr. Tine Dusauchoit of Mdecins Sans Frontires
(MSF), Belgium and Ms. Patricia Hindmarsh of Marie Stopes
International.
Dr. Dusauchoit mentioned that, as significant progress has
now been achieved in dealing with emergency relief, it is
necessary to address issues which have been neglected and
reproductive health is among them. The symposium is timely in
this regard and is the first step in the direction of achieving
the provision of reproductive health care of good quality. Dr.
Dusauchoit also mentioned that it was necessary to provide tools
and guidance to field staff in order for them to tailor the
activities to each specific setting and according to priorities.
Ms. Hindmarsh gave a brief description of the work of the
newly-created Reproductive Health for Refugees Consortium,
comprising four agencies - John Snow Inc., International Rescue
Committee, CARE and Marie Stopes International - whose common
goal was to ensure that reproductive health was incorporated and
institutionalized in programmes servicing refugee communities.
The Consortium is supported by a secretariat provided by the
Women's Commission on Refugee Women and Children. Ms. Hindmarsh
concluded emphasizing the need for further coordination and
cooperation with other NGOs and UN agencies.
Finally, Dr. Ljiljana Kordic, a refugee representative,
described her own experience as a woman in Croatia, and recalled
that during this period reproductive health services were almost
totally absent.
Dr. Sadik then handed the chair to Ms. Yvette Stevens, Chief
of Programme and Technical Support Section, UNHCR.
2.2 PROCEEDINGS OF THE TECHNICAL DISCUSSIONS
The next phase of the Symposium involved two panel
discussions on the challenges and solutions to making
reproductive health a reality in refugee situations. Summaries of
these are provided in Chapter 2.
Before closing for the first day, Ms. Yvette Stevens, on
behalf of the participants, thanked Dr. Daniel Pierotti (of
UNFPA) and Dr. Serge Mal (of UNHCR) for their contribution to
the organization of the whole process including the Symposium
itself.
Acting on behalf of the Secretariat of the Symposium, Dr.
Serge Mal presented the first draft of the Field Manual on
Reproductive Health in Refugee Situations (hereafter referred to
as "Field Manual") to be used as a basis for discussion in the
Working Groups meeting on Day 2 in UNHCR Headquarters.
On the second day of the Symposium, the participants
separated into seven working groups. The aims of each group were
to:
a) focus on a pre-determined "cross-cutting" issue and examine
the weight it should be accorded in each chapter of the
Field Manual; and
b) review and discuss the general content, presentation and
format of the Field Manual.
Reports of the discussions of each of the Working Groups
appear in Annexes I through VII, as follows:
I. WG 1: Integration of RH services into existing
projects
II. WG 2: Community Participation
III. WG 3: Minimum Initial Service Package
IV. WG 4: Information, Education and Communication
V. WG 5: Human Resources in RH and training
VI. WG 6: Overall review of the draft Field Manual
VII. WG 7: Implementation
2.3 MAIN CONCLUSIONS AND RECOMMENDATIONS
On the third and final day of the Symposium, representatives
of each Working Group presented their groups' conclusions and
recommendations in plenary under the chair of Dr. Pramilla
Senanayake of IPPF and Ms. Yvette Stevens of UNHCR, as co-chair.
A general summary of the main points made in each presentation
appears in Chapter 3.
A number of significant conclusions and recommendations
regarding reproductive health care in refugee situations,
generated during the preparatory meetings and the Symposium were
drafted with input from each of the working groups. Shortly
before the closing of the Symposium, a draft text was read to the
plenary by the co-chairs. It was agreed that the text would be
circulated and finalised, based on the comments of participants.
The document, Main Conclusions and Recommendations from the
Inter-Agency Symposium on Reproductive Health in Refugee
Situations, may be consulted in Chapter 5 below.
2.4 CLOSING REMARKS
In closing, Dr.Nafis Sadik and Mrs. Sadako Ogata, United
Nations High Commissioner for Refugees, briefly addressed the
participants of the Symposium.
Dr. Nafis Sadik opened her statement with congratulations to
the participants for three days of hard work and achievements and
announced the signing of a Memorandum of Understanding between
UNFPA and UNHCR for further collaboration. UNFPA will participate
in the follow-up activities as planned and in particular to the
Inter-Agency Working Group (IAWG).
Dr. Sadik said that UNFPA's Executive Board has authorized
to make readily available the necessary funds to cover the costs
of reproductive health activities for refugees and displaced
persons. The resources would be allocated through the program of
assistance to the host country and be complemented when needed.
More specifically, she pledged UNFPA's strong support for the
following:
* training in all the components of comprehensive reproductive
health care;
* appropriate response to the problem of sexual violence,
which includes rape and harmful traditional practices,
firmly backing the Symposium consensus for improved
enforcement of protection measures and access to emergency
(post-coital) contraception;
* supply of necessary drugs, contraceptives and other medical
equipment to meet the reproductive health needs of refugee
women and men. To facilitate procurement of contraceptives
and supplies to reproductive health programmes in emergency
settings, Sadik said UNFPA plans to establish a Global
Contraceptive Facility.
Mrs. Sadako Ogata, United Nations High Commissioner for
Refugees, addressed the Symposium at the close of the last day.
She reminded participants of the Fourth World Conference on Women
in Beijing to be held in September and the opportunity it would
present for mobilizing more resources to carry out reproductive
health activities in refugee situations. Her closing remarks
raised four basic issues:
* The use of sexual violence as a means of persecution for
reasons of race, ethnicity, nationality or political opinion
is a major problem. UNHCR's Executive Committee condemns
this practice, which is a serious human rights violation as
well as a breach of humanitarian law in war. The recently
published UNHCR Guidelines on Sexual Violence, along with
the in-progress Field Manual on RH, and an awareness of the
need for more qualified female staff, are important steps
towards strengthening UNHCR protection and assistance role
in the field.
* The integration of comprehensive reproductive health
services into preventive health care calls for a multi-
sectoral approach. This has been too long overlooked.
* Reproductive Health programmes should aim to be self-
supportive and sustainable. Training of refugee health
workers who can benefit the community both in the home and
host country is crucial and, upon repatriation, may provide
a "spring-board" for the rehabilitation of the basic health
sector in war-torn societies.
* In light of the scale and the multi-faceted nature of the
problem, the strengthening of partnerships among agencies,
governments, the refugees and host communities is of the
highest priority. At the heart of this collaborative
process must be the refugees themselves. Their full
participation in design, development, implementation and
evaluation of programmes is key.
Mrs. Sadako Ogata concluded expressing her appreciation for
the work which has been achieved and hoping that this symposium
will form the basis for actions geared toward concrete results.
She finally mentioned the commitment of her Office to implement
an effective reproductive health strategy in refugee situations.
Before officially calling the Symposium to a close, the co-
chairs and representatives of the Secretariat warmly thanked all
the participants and the UNFPA and UNHCR staff in charge of the
organization for their untiring support.
=================================================================
3. SUMMARY OF THE PANEL DISCUSSIONS
3.1 FIRST PANEL DISCUSSION
MAKING REPRODUCTIVE HEALTH ACTIVITIES A
REALITY IN REFUGEE SITUATIONS
Wednesday 28 June 1995
11:30 - 13:00
Moderator: Dr. France Donnay (UNICEF, New York)
Panelists: Dr. Tomris Trmen (WHO)
Dr. Peter Poore (SCF, UK)
Ms. Barbara Smith (IRC)
In the first of the two panel discussions, three panelists
addressed the issue of how to make reproductive health care a
reality in refugee situations. Dr. Tomris Trmen gave an
overview of the scope of the problem and a framework for action,
setting the stage for the more detailed discussions to follow.
Dr. Peter Poore focused on what he sees from an NGO perspective
as the main challenges to implementing reproductive health
programmes for refugees. Finally, Ms. Barbara Smith spoke on the
challenges for which no clear solutions are yet at sight like the
response to victims of sexual violence.
Dr. Trmen summarized the WHO Framework for Action for
Reproductive Health in Refugee Situations. Her overview
highlighted the vulnerability of refugees to sexual and
reproductive ill-health and the critical points in the life cycle
at which intervention is neglected. Dealing with the threat to
reproductive health in refugee settings requires more than
biomedical interventions; it involves improving underlying causes
of illness such as poor living conditions, access to resources
and education as well as dealing with social and cultural
determinants of ill health. It means promoting awareness of self-
help and self-care and it involves partnerships with NGOs and
national and international organizations.
The panelist advanced the need for an integrated approach to
service delivery, in contrast to the traditional focuses on a
particular problem such as STDs or a technology such as family
planning. Such an approach improves access and quality of
services and is more cost-Implementing comprehensive reproductive
health strategies means recognising the interdependency of
interventions and expanding the range of options offered in
community-based and clinic-based services. However, reproductive
health priorities should be: family planning information and
services; prevention of maternal and newborn deaths and
disabilities; prevention and management of STDs; and special
measures to protect the rights and safety of girls and women.
In closing, Dr. Trmen acknowledged the challenges ahead.
Faced with an absence of political will, shrinking resources and
legal barriers, we must marshall the sustained political
commitment and resources required to make this comprehensive
reproductive health approach a reality in refugee conditions.
Dr. Poore, in his presentation of an NGO experience in the
introduction of Reproductive Health Services, outlined what he
called "severe logistical constraints" affecting NGOs and other
agencies in implementing services and underscored the need to
acknowledge and solve these fundamental difficulties.
The poverty and deteriorating health conditions of many host
and home countries pose a major problem. Despite their legal
responsibility to provide for the refugees, most host countries
have no capacity (and sometimes no interest or, worse, active
hostility toward the refugees) to meet the needs of refugees. In
many cases, they cannot provide for their own local populations.
The gap between needs and resources for service delivery is
related to another problem: short-term investment by donors and
unwillingness to invest in the capacity of host and home
countries to deliver services. Donors are supplying short-term
emergency funds for what is indeed an "emergency" but for which
the solutions require long-term funding. Given that funds are
increasingly unreliable and conditional on media interest and
political expediency, the "forgotten" emergencies are left with
no resources.
This resource dearth is at the root of yet another
constraint: competition among the UN agencies and NGOs. These
rivalries limit willingness to share information and hinder
active coordination and rational use of existing resources, said
Dr. Poore.
Lastly, Dr. Poore spoke of poor quality care, which is a
denial of human rights. To improve our logistical capacity, he
pointed out, we must ensure safe and effective care. With the
ever growing number of agencies with an interest and/or presence
on site, the need for accountability and standards is greater
than ever. The current situation is one not only of quantity but
also quality. Poor management of resources, often by NGOs, is a
major reason for widespread poor quality care. This lack of
quality care underscores the need for standards and a code of
practice, a minimum level of competence, and training on a
continuous basis.
Ms. Smith opened with a reminder to all of the crucial and
long-overdue task of this gathering -- to formalize the needs of
80 percent of the refugee population -- women and children.
Inherent in the broadening of the definition of reproductive
health are some challenges unrelated to technological or medical
advances but equally critical to pursue. Even though the
responses to challenges are not easy to tackle, it is important
to confront them.
Among these key issues, according to Ms. Smith, is
protection against sexual violence. Some of the solutions are as
simple as building fences or lighting; others are as complex as
the issue of the guard as perpetrator. In dealing with this
issue, which tactic is most effective: quiet diplomacy or
screaming?
A related issue involves the ravages of sexual violence,
according to the panelist. The traditional counselling and mental
health treatment techniques for survivors of sexual violence are
not geared to women continuing to live in a war zone. In fact,
they are likely to put these women at increased risk. In normal
situations, explained Ms. Smith, the healing process should
involve the breaking down of a person's emotional defenses to
reach the hidden pain. Life in a war zone calls for the contrary:
to survive, one must cover over and keep up one's guard. Therapy
is supposed to be a safe place, a support person someone to
trust. In a war zone, the people helping are likely survivors
themselves with the same problems. In cases where the therapists
come from outside the population, often they, too, are
traumatized by the conditions, often literally shaking from the
shelling. Under normal conditions, the point of therapy for
sexual violence is to re-integrate the victim into mainstream
life. In war situations, there is nowhere "normal" to go.
Next, the panelist addressed the issue of how to protect
women in leadership roles. Placing women in control of food
distribution, for example, is akin to giving them status of "king
for a day or a millennium," said Ms. Smith. It is a life-
threatening position. Contrary to men, a woman's day-to-day
status doesn't change so much. Given men's loss in status and
purpose, and the prevailing boredom and violence of the camp
situation, it is critical to look at what this means for the
safety of women.
Ms. Smith also raised the important question of protection
for men against sexual violence and help for the survivors of
such violence.
Finally, she closed with mention of two difficult challenges
of another nature: prioritizing essential reproductive health
care components from day one of an emergency response and, in
more stable situations, deciding the feasibility of screening and
treating reproductive cancers (in fact, a more common killer of
refugee women in developed countries).
The discussion generated by the panelists focused mostly on
what to do in the acute phase when priority is critical. Ms.
Smith, answering her own question about priority air shipments,
said that she believed it was wrong to let babies starve or
mothers die in childbirth. A CARE representative spoke in favour
of distributing condoms and food at the same time, saying that
condoms should be no lesser priority than food if one's goal is
protection of life. The working group discussions on the Minimum
Initial Service Package (see Annex III) would go into further
detail to define what is to be implemented from the start of a
new refugee operation.
There were pleas for more coordination and cooperation among
agencies and within agencies between field staff and
headquarters. On the issue of protection, there was agreement
that the leadership roles for women were further aggravating
violence problem by taking away men's traditional role.
=============================================================
3.2 SECOND PANEL DISCUSSION
LEGAL, ETHICAL AND HUMAN RIGHTS ISSUES
ON REPRODUCTIVE HEALTH IN REFUGEE SITUATIONS
Wednesday 28 June 1995
15:00-16:30
Moderator: Ms. Ann Howarth-Wiles (UNHCR, Geneva)
Panelists: Mr. Guy Goodwin-Gill (Faculty of Law, Amsterdam)
Ms. Karin Landgren (UNHCR, Geneva)
Dr. Doris Schopper (WHO, Geneva)
The purpose of this panel was to establish a clear
understanding of legal frameworks applicable to reproductive
health in refugee situations and the scope of the protection they
offer. As the first panelist, Mr. Guy Goodwin-Gill reviewed the
human rights involved in securing access to reproductive health
care and information. Next, Ms. Karin Landgren followed with a
more focused examination of the special legal issues raised by
sexual violence in refugee settings. Finally, Dr. Doris Schopper
addressed the controversial question of HIV/AIDS testing for
refugees within the context of human rights.
Mr. Goodwin-Gill opened with an overview of the legal,
ethical and human rights issues relating to reproductive health
in general and specifically in the context of refugee situations.
The panelist began by explaining the need for an holistic
approach to health care in refugee situations an approach which
has yet to be applied owing to the presumed "temporary" nature of
displacement, the practical concerns of immediate service
delivery, the current prioritization of services, and the
reticence of host States to treat refugees the same as nationals.
However, refugees are often in special need of complete health
care owing to the risks of marginalization in the local community
and their inability to pay for this form of care during exile.
To deal with the problem, the panelist explained the
existence of basic human rights in the area of health rights
defined and recognized in various instruments and held by all
individuals, including those in exile. In this connection, he
elaborated on the emerging and consolidating recognition of
health (including reproductive health) as a human right and, by
extension, the right to be informed, to have access to services,
and to be protected against threats to health. Various provisions
relative to reproductive health found in international and
regional human rights instruments were illustrated.
In conclusion, the panelist stressed the responsibility of
United Nations agencies such as UNHCR, UNFPA and WHO to help
secure these rights for all individuals, adding that failure to
do so would effectively result in a violation of these
internationally recognized human rights. He also addressed the
responsibility of these agencies not to shelter behind the
sterile argument of cultural relativism that fails to allow
individuals the freedom to choose.
Ms. Karin Landgren opened with a brief description of the
many violations suffered by survivors of sexual violence. These
breaches of fundamental human rights, including the right to
security of person and the prohibition of cruel, inhuman or
degrading treatment, are accompanied by the repercussions of
sexual violence such as trauma, stigmatization, rejection, STDs
and unwanted pregnancy.
The panelist described how sexual violence in refugee
situations is no longer an unspoken threat but an overt problem.
A selection of cases was presented to illustrate the protection
problems arising in refugee situations as well as their long-term
effects (such as the continuing discrimination, and even
persecution, of victims following repatriation).
Having established the gravity of the problem and its
repercussions, the panelist made two important recommendations.
The first was the indispensable nature of a "rights-based"
approach to protecting and assisting refugee women. This is an
approach which UNHCR has maintained in its recently published
Guidelines for Prevention and Responding to Sexual Violence
against Refugees. This is readily evident in Chapter I of the
Guidelines which addresses ways to prevent sexual violence or
seek redress for victims by drawing upon national and
international law. The strength of this approach lies in the fact
that it places both awareness of, and responsibility for,
ensuring protection of human rights within UNHCR's functions.
As a second recommendation, Ms. Landgren highlighted the
importance of education, specifically human rights awareness
training, among refugees as a way of concretizing the rights-
based approach, with the understanding that knowledge of rights
is crucial to combatting sexual violence. As proof of its
commitment to this approach, UNHCR has begun working on legal
awareness training for refugee women.
Discussion arising from the presentation centered mainly on
the possibility of conflicting views between the host country and
agencies implementing reproductive health activities. More
precisely, participants addressed the dilemma faced by health
workers when a woman seeks or requires an abortion where it is
prohibited by law in the host country. Ms. Landgren responded by
stressing that the legal framework which must be respected is
always that of the host country. Staff must therefore respect
national laws, including those prohibiting abortion. However,
UNHCR and other agencies may take on the role of advocacy to spur
changes in laws which are detrimental to good health or, in the
case of States parties to human rights conventions, in
contradiction with conventional obligations. In a similar
context, the legal framework to be used to seek redress for
sexual violence, must be that of the host country. In response to
a question regarding the use of (post-coital) contraception, Ms.
Landgren again explained that it may be offered in countries
where modern contraception is already used.
Dr. Doris Schopper opened her remarks with a discussion of
the roots for much discrimination of individuals with HIV/AIDS,
citing the ignorance of routes of transmission, the pre-existing
disapproval of certain groups or lifestyles/behaviours, and the
fear of infection, disease and death as primary among these. The
panelist also described why women and children face greater risks
of transmission.
In the more specific context of human rights, Dr. Schopper
called for greater emphasis on the protection of human rights as
a means of promoting public health. This could only be achieved
through appropriate information, education and communication
(IEC) strategies. She also addressed the issue of mandatory HIV
testing in refugee situations. Such testing, she stressed, should
not be pursued as a matter of policy either in general or within
the refugee context, a position which is sustained by the WHO.
Mandatory testing of HIV/AIDS, she explained, does nothing to
stop the spread of the virus, represents a violation of human
rights, and leaves those identified as HIV-positive open to
discrimination. Moreover, if no follow-up treatment or assistance
is made available (which is more often the case) testing becomes
useless. Even voluntary HIV testing and counselling in a refugee
situation should not be a priority. Rather, scarce resources
would be better used for other activities such as for blood
screening (to ensure a safe blood supply for transfusions) or for
education and the provision of condoms.
As final words, Dr. Schopper suggested a number of general
principles which could form the basis of successful HIV/AIDS and
STD interventions in refugee situations. These include, among
others, integrating HIV/AIDS and STD interventions into other
health and social activities (to reduce the risk of
stigmatization) and obtaining the support of community leaders to
address sensitive issues such as sexuality.
In the discussion which followed, concerns raised by the
audience focused on the likelihood of discrimination against
HIV/AIDS infected persons in the process of resettlement. Dr.
Schopper explained that, even though experts strongly agree that
mandatory testing is not at all a deterrent (given the realities
of travel and the fact that a recently infected person may not
immediately test positive), such testing is becoming common. As
an example, she clarified, testing for HIV/AIDS is mandatory for
resettlement in some countries, and indeed, the International
Office of Migration even provides HIV/AIDS testing to
resettlement candidates because it is a condition imposed on them
by receiving countries. She further explained that the argument
used for restricting entry to HIV/AIDS infected is usually one of
politics and economics and that, despite WHO's strong stance
against such discrimination, the reality is that each State has
absolute authority to decide the basis for restricting entry of
non-nationals.
=================================================================
4. SUMMARY OF WORKING GROUP PRESENTATIONS
4.1 GROUP 1: INTEGRATION OF REPRODUCTIVE HEALTH INTO
EXISTING PROGRAMMES FOR REFUGEES
Ms. Lauren Gilbert of the Washington College of Law
presented the conclusions and recommendations of this group,
beginning with a set of general guiding principles on which to
build feasible and sustainable reproductive health programmes.
The principles also define the constraints and pitfalls which may
arise and which must first be tackled.
The group also addressed the issue of human resources as a
principal factor for adequate integration. It stressed that, when
a host country is incapable of providing reproductive health
services, it is the responsibility of the international community
to fill the gap. In order to respond to this gap, it was
recommended that field staff from all the organizations involved
in reproductive health activities facilitate the provision of
services.
Following this, the group identified "pathways" to ensuring
the integration of reproductive health services and the human
resources which can be tapped at various levels to assist in this
integration. These were presented in the form of an easy-to-
follow grid provided in Annex I.
The discussion generated by the presentation centered on the
need for international organizations to communicate their
commitment to reproductive health in refugee situations to their
officers in the field so that implementation and integration
truly take place.
4.2 GROUP 2: COMMUNITY PARTICIPATION
Dr. Ritu Sadana of Harvard University, speaking on behalf of
this group, said the group clearly described strategies for how
community participation can support reproductive health
activities. The group defined a number of "types" of
participation. Community participation can be in the form of
labour, planning and decision-making. Field managers should
understand that the forms and roles of community participation
will differ depending on various factors such as: a) the phase of
the situation, b) the leadership structure of the community, c)
the perceptions held by the community regarding sexuality and
reproduction, and d) the existing skills of the population.
The importance of community participation as a means of
developing a sustainable reproductive health programme, and also
obtaining more justice and gender equity, particularly for women,
in decisions about the distribution of resources and reproductive
health services, was also highlighted. With regard to the latter,
however, it was noted that empowering women within refugee
settings is not a spontaneous process, and that the support of
the international organizations is therefore crucial.
It was suggested that the Field Manual include a range of
examples of field experiences that illustrate community
participation strengthening reproductive health services. A
framework in the form of a table was presented as a means to
guide community participation through the phases of both the
refugee situation and the programme needs (i.e. design,
implementation and evaluation).
Finally, this presentation closed with examples by three
group members of their own experiences with successful community
participation.
A short debate ensued about whether to involve the host
community. Since interaction between the refugee and host
communities inevitably occurs, it was agreed that the latter
should be invited to participate.
4.3 GROUP 3: MINIMUM INITIAL SERVICE PACKAGE
Dr. Enric Freixa of Mdecins Sans Frontires (Spain) began
his report of the group's conclusions with an explanation of what
the group saw as its mandate: formulate a package of activities,
not just a list of materials, that represents an appropriate and
feasible response to reproductive health needs of refugees during
the early phases of a new refugee situation.
He emphasized that the package was a strategy designed to
suit any refugee situation, specifically intended be used
"blindly", without any requirement of needs assessment. As a
standardized "minimal" and "initial" response, the group focused
on priority needs and chose simple, feasible, rapid and effective
activities to meet those needs.
The group identified four priority objectives: protection
against sexual violence; free provision of condoms; enforcement
of universal precautions against HIV; and safe delivery and
treatment of unsafe/complicated abortions. Using a simplified
version of the logical framework, the group converted the
problems into objectives and then the activities and
inputs/resources required for meeting the goals. For example, the
goal of universal precautions requires two specific activities:
training and provision of extra disposable materials (WHO kit).
Time for training and a specific kit are the resources needed.
The two-pronged goal of access to safe delivery and treatment for
incomplete/complicated abortions would require three activities:
identification of referral points and their strengthening if
necessary; means of transport with 24-hour availability, and
training. Training time, a kit (TBA/midwife), means of
transportation and medico-surgical equipment are the resources.
Concerns addressed by the audience focused on the "minimal"
aspect of the package, with strong feelings expressed that even a
minimal strategy should include emergency contraception and
breastfeeding promotion. There was also discussion and
clarification regarding the term "blind" strategy. It is a
misnomer because, in fact, the "blind" package here is based on
extensive field experience about what is needed in the crisis
phase. It is a package that can be implemented from the first
day, designed to be in place before and during the formal needs
assessment activities. It was emphasized that this package is not
intended to replace the reproductive health package determined
after needs assessment.
4.4 GROUP 4: INFORMATION, EDUCATION AND COMMUNICATION
Ms. Beverly Tucker of Family Health International,
presenting the findings of this group, described Information,
Education and Communication (IEC) and its link to empowerment,
mobilization and behaviour change. Simply making reproductive
health services available to women and men is not enough; IEC,
including counselling, are crucial and complementary aspects of
clinical reproductive health care and should be an integral part
of services for refugees.
Effective IEC requires careful understanding of the audience
and of the cultural context. As field managers are not
necessarily IEC experts, the group suggested that the manual
focus more on "how to" guidance regarding design and
implementation of IEC programmes. The IEC sections in the various
chapters should be removed and replaced by a reference to an IEC
annex, a comprehension treatment of the subject. In the
introductory chapter of the manual, IEC would be introduced as a
cross-cutting topic and then a reference added to the annex on
IEC.
Regarding the manual in general, the group had several
suggestions. The manual should be divided into two parts, one a
bulleted format similar to "Facts for Life" and a second more
detailed section. Use of a binder would allow for updates and
tailoring for specific situations. The manual needs to be more
instructional, include more discussion of how to tackle the
problem of integration of reproductive health care into other
primary health care services. There was consensus that the draft
manual was too specific to refugee situations in Africa and less
relevant to Europe, Asia and Latin America. The group also agreed
that the manual was too narrowly focused on refugees in camps as
opposed to those in integrated, hidden or non-camp refugee-like
situations.
Comments following the report demonstrated some concern
regarding the degree to which the current draft manual was
applicable to regions other than Africa.
4.5 GROUP 5: HUMAN RESOURCES FOR REPRODUCTIVE
HEALTH AND TRAINING
Ms. Nancy Pendarvis Harris of John Snow Inc. presented her
group's recommendations on training at the field level. The group
called for a holistic approach to training, with identification
of various categories of camp personnel to be trained,
integrating all elements of comprehensive reproductive health in
basic general training in health at camp level rather than
separate training in each technical area. It was recommended that
a participatory and not prescriptive approach to training needs,
one involving trainees in design and assessment of their own
needs, would be most effective. Equal gender distribution of
trainees was recommended.
The group suggested adding a training matrix detailing the
type of worker, including non-health workers such as protection
officers, and content of curricula. Curricula content should not
be limited to merely technical skills; inter-personal
communication and counselling, gender awareness and humanitarian
law and protection issues should be included.
The group recognized the importance of budgeting for these
training programmes and urged headquarters and programme staff to
carefully assess costs and allot for continuous/ refresher
training. The group identified improved inter-agency coordination
on this and other issues as a major concern.
A reproductive health coordinator should be appointed to
facilitate training and service delivery even in an otherwise
integrated primary health care programme. Three other
recommendations on the manual and training included qualitative
training indicators for evaluation, special instructions
regarding emergency contraceptive training, and more visual aids
(in the Manual).
Comments from the audience included a suggestion for using,
when possible, curricula from refugees' home country. Despite
cost of on-going training, said another participant, the fact is
good quality service means continuous training. The
recommendation for "reproductive health coordinators" stirred
debate, with several participants questioning how feasible or
even necessary such would be in some camp situations. Should
there be a reproductive health coordinator when, for instance,
there is no nutrition coordinator? Another comment addressed the
need to include men in training and/or as targets.
4.6 GROUP 6: DRAFT FIELD MANUAL
As chair of this working group, Dr. Serge Mal gave a brief
summary of some of the issues tackled by its members. He began by
explaining the group's consensus that field and programme
managers would remain the primary target audience for the Field
Manual, as they would ultimately be responsible for overseeing
the implementation of reproductive health activities in refugee
settings.
A new, more concise, format for the introduction to the
manual was devised by the group, consisting of a brief preface,
general and specific considerations, and guiding principles and
strategies for implementation. The group also concluded that not
all chapters in the manual would be stylistically or structurally
identical given that some were more of a technical nature than
others.
A number of suggestions generated by the presentation
involved the actual structure and presentation of the final
document. One participant called for a clearer, step-by-step
approach within each chapter so that the information would be
easy to follow, while another warned that a too bulky manual
would defeat the purpose.
In terms of content, it seemed to be generally agreed that
the manual should be in a "cookbook" form, that is, detailing
exactly what should be considered and who should be responsible
for implementing specific activities. This manual would serve as
a general guide to a variety of staff, while technical guidelines
(such as the in-progress WHO Technical Guidelines on Reproductive
Health for Populations in Transition) would serve as resource
material to be supplied on demand.
In response to a question regarding the incorporation of
refugee phases within the chapters, Dr. Mal explained that each
chapter would not be identical and phases would be used only when
useful.
4.7 AD HOC WORKING GROUP ON IMPLEMENTATION
An ad hoc working group was formed, led by representatives
of USAID and composed of representatives of a number of NGOs and
UN agencies. The aim of the group was to create a framework of
follow-up mechanisms to ensure the implementation of reproductive
health services.
As spokesperson for the group, Dr. Cate Johnson of USAID
described the main goals identified by the group as essential for
effective implementation:
a) systematically implementing and integrating reproductive
health activities in refugee situations for the next five
years;
b) finalizing, operationalizing and field testing the Field
Manual.
The group proposed the creation of an Inter-Agency Working
Group (IAWG) spearheaded by UNHCR to facilitate implementation.
A person should be seconded to UNHCR to coordinate this task. The
IAWG would collaborate with, ad hoc and institutional advisory
bodies.
Participants approved these suggestions with the provision
that clear terms of reference should be established by the
Secretariat to maximise the potential inputs and efficiency of
the IAWG and to ensure complementarity of recommended activities.
=================================================================
5. MAIN CONCLUSIONS AND RECOMMENDATIONS
In light of the discussions during the closing session and
written comments provided by the participants, the following
constitute the main conclusions and recommendations of the
Symposium:
QUOTE
Some 135 people from 50 agencies participated in the Inter-
Agency Symposium on Reproductive Health in Refugee Situations
which was held in Geneva from 28 to 30 June 1995. The overall
objectives of the Symposium were to define the main reproductive
health activities to be established in refugee (or refugee-like)
situations, and to promote their implementation or strengthening.
Rationale
1. Reproductive health activities, whenever implemented, have
often been limited to Maternal and Child Health care and
more recently, due to the HIV/AIDS pandemic, ad hoc
distribution of condoms has been added. However, there has
been no systematic strategy for a comprehensive reproductive
health care.
2. The delivery of reproductive health services in refugee
situations has been hampered by factors like the low
priority given to it by organizations and agencies
specialised in emergency response.
3. Family planning is often considered a sensitive issue in
post-conflict situations and refugee women's own views and
support have not been consistently sought or revealed.
4. There have been insufficient professional staff in the field
and existing staff have been often only partly qualified in
planning and implementing reproductive health services.
5. Long-term planning and coordination, essential for
sustainability of health activities, including reproductive
health, have been handicapped by limited funding and
resources or inadequate resource allocation on the part of
the funding institutions.
6. Not enough attention has been paid to coordinating with
national authorities, NGOs and UN agencies in the country of
asylum.
Taking into account the above mentioned limitations and to
meet the overall objectives of the symposium, the participants
made the following recommendations:
Guiding Principles
1. Refugees, and especially women and adolescents, have the
fundamental human right to receive the reproductive health
services they need and request, just as any other
population,
2. Essential minimum reproductive health services should be
made available at the outset of all refugee operations
through the Minimum Initital Service Package (see below for
its contents),
3. As soon as possible, reproductive health activities and
services should be implemented in full and integrated within
existing primary health care, community or protection
services as relevant,
4. If needed and to the extent possible, reproductive health
services should also be made available to the local
population surrounding the refugee settlements,
5. Close collaboration should be established with local health
authorities in order to facilitate the harmonisation and
sustainability of services,
6. Quality of reproductive health care is essential and
requires adequate training and cultural sensitivity on the
part of providers, respect for confidentiality and privacy,
appropriate location of services, adapted and adequate
equipment and continuous and regular supplies,
7. Coordination of reproductive health activities between all
groups providing services is essential to ensuring
complementarity and cost-effectiveness. To this effect, a
focal point on reproductive health should be identified as
early as possible in all refugee operations,
8. Community participation in the planning and delivery of
reproductive health services is absolutely essential to
ensure that the needs and expressed demands of people are
identified and met in a culturally appropriate way.
Implementation
1. At the outset of all refugee operations, a Minimum Initial
Service Package (MISP) should be made available and the following
actions implemented immediately:
* safe delivery practices
* free availability of condoms
* prevention and treatment of unsafe abortion
* application of universal precautions against the spread of
HIV/AIDS
* contraception on demand, including emergency contraception
* identification of appropriate sites
* gathering of basic health and socio-cultural data on the
country of origin
* identification of a Reproductive Health focal point
2. As soon as feasible and based on an appropriate needs and
resources assessment, a comprehensive and culturally sensitive
reproductive health project should be executed and should include
the provision of counselling and clinical services in the
following areas:
* prenatal, delivery and postnatal care
* family planning or child-spacing
* prevention and management of sexual and gender-based
violence
* prevention and control of STDs including HIV/AIDS
* prevention and care of gynaecological complications
3. Referral systems should be established as soon as possible
for essential obstetic care (EOC). Local health facilities
should participate in the provision of care. This may require
technical and financial support from concerned agencies involved
in reproductive health services.
4. On-going monitoring and surveillance, to tailor the
services to evolving demands and needs, should be initiated as
soon as possible using basic indicators, broken down by gender
and age.
5. Culturally sensitive Information, Education and
Communication (IEC) services are essential for the development
and effective implementation of appropriate projects.
6. Personnel providing reproductive health services should be
adequately trained in technical, interpersonal communication and
counselling skills. The cultural sensitivity and appropriateness
of personnel is essential to the success of activities.
Follow-up actions
1. An Inter-Agency Working Group (IAWG) will be established
under the co-ordination of UNHCR. Its main tasks will consist of
organising and facilitating reproductive health services in
refugee situations. This will include: exchange of information,
advocacy, planning, training, assessment, monitoring, co-
ordination, research and evaluation. Its first task will be to
finalise and operationalize the Field Manual on Reproductive
Health in Refugee Situations. The membership to the IAWG should
be an appropriate balance of NGOs, UN agencies, governmental
agencies and donor institutions.
2. The Field Manual will be developed as a tool to facilitate
the implementation and coordination of reproductive health
services. The manual is intended for field staff involved in
providing health, nutrition, community and protection services.
It will be finalised in the coming months and field tested over a
period of two years before a revised version is produced.
3. The Inter-Agency Working Group will collaborate with other
bodies such as:
i) the WHO Consultative Group on Reproductive Health, that
will develop technical guidelines on reproductive
health for persons in transition;
ii) the Reproductive Health for Refugees Consortium (Care,
IRC, JSI, MSI and WCRWC);
iii) the working group on reproductive health kits (MSI,
UNFPA, WHO) etc.
=================================================================
ANNEX I
REPORT OF WORKING GROUP I
INTEGRATION OF REPRODUCTIVE HEALTH SERVICES INTO EXISTING
PROGRAMMES FOR REFUGEES
Chairperson: Dr. Daniel Pierotti (UNFPA)
Resource Person: Ms. Rosalud De La Rosa (UNHCR)
Rapporteurs: Ms. Lauren Gilbert (Washington College of Law)
Dr. Mohamed Qassim (UNHCR, Bangladesh)
Ms. Mari Sasaki (UNFPA)
1. Lengthy discussions delineated the preliminary conditions
for establishing reproductive health services and integrating
them into existing primary health care services. The following
points were highlighted:
- In refugee situations, implementation and integration of
reproductive health services should be guided by the
principle that all human rights must be protected and
promoted, especially concerning women.
- Reproductive health may not be seen as a priority by
refugees or refugee health service providers, and
consequently not offered to the population.
- The provision of comprehensive reproductive health services
should be identified as a priority sector by concerned
agencies.
- Refugee situations may differ according to the degree of
support provided by the host country. Where a host country
is not willing or able to make reproductive health services
available, it should be the responsibility of the concerned
agencies.
- Implementation of reproductive health services may vary
depending on the refugee environment, on the composition
of the refugee population and on the skills and resources
of local and international partners.
- Reproductive health services for refugees must be based on
perceived as well as real needs. Service providers must be
sensitive to perceived needs, traditions and cultures.
- Participation of women in the decision-making process and
their access to reproductive health care services must be
ensured. Implementation of reproductive health services
should be guided by existing UNHCR policies and programmes
for the protection and assistance of refugee women,
including UNHCR Guidelines on the Protection of Refugee
Women and The Guidelines on Prevention and Response to
Sexual Violence Against Refugees.
- Agencies should identify financial and human resources and
personnel with the necessary skills to implement and
integrate reproductive health care services, to train
others and to continue providing reproductive health
services when resources are becoming scarce.
- Integration of new services such as reproductive health may
sometimes call for drastic reorganization of existing
services. Wherever possible, it is advisable to insert
reproductive health activities into existing services so as
not to disrupt other services.
2. Integration of services
- Integration can only be operational when the situation is
stable. In the initial phases essential reproductive health
services, including emergency contraception, should be
provided whenever possible.
- Integration of reproductive health care services into
existing structures must take place at all levels:
community; primary health care; and at referral level.
- Continuity between each level of services is an essential
principle of integration and facilitates quality of care.
- Integrated reproductive health services should always seek
to utilize and strengthen existing human resources,
including those within the refugee community.
- UN agencies and NGO staff should work closely with UNHCR
health coordinators in developing reproductive health care
services in refugee camp settings, in order to ensure
coordinated joint activities.
3. Integration of different components of reproductive health
services at various levels of care:
- In order to faciliitate integration of reproductive health
services, a framework was designed by the group to respond
to the various reproductive health needs of women in
specific situations/conditions.
=================================================================
TABLE 1: Integration of sectoral reproductive health services at
various levels of care
WHAT PURPOSE WHERE HOW WHO
-----------------------------------------------------------------
Family Avoid Community Spacing
Planning Unwanted pregnancies CBD workers
Pregnancies Post partum FP ACES
Post Abortion FP HITS
Emergency TBAS
Primary Contraception
Health
Care
Services Nurses/
Midwives
Physicians
Pregnant Early Community Pre-natal care TBAS
Women identification Labour and
of risk factors delivery
referral to EOCs Post partum
Improved Labour
delivery
Treatment of Referral of
abortion gynaeological Nurses/
complications & and obstetrical Midwives
safe abortions complications Physicians
to EOC
STDs Prevention Community IEC TBAS
Screening Counselling ACES
Syndromic HITS
screenings
Condom CBD
distribution
Treatment Primary Antibiotics Nurses/
health Midwives
care and Physicians
referral
institutions
AIDs Prevention Community IEC ACES
Counselling
Condom
distribution
Gender & Prevention Community Counselling ACES
Sexual and treatment Emergency HITS
Violence of conse- Social contraception CBD
quences services Community TBAS
of rape and awareness Protection
FGM Officers
=================================================================
ANNEX II
REPORT OF WORKING GROUP II
COMMUNITY PARTICIPATION
Chairperson: Sister Anne Thompson (WHO)
Resource Person: Ms. Lucie Blok (MSF, Holland)
Rapporteurs: Ms. Sara Butterfield (IPPF)
Ms. Marie Lobo (UNHCR)
Dr. Ritu Sadana (Harvard University)
Preamble
Community participation was identified by the participants
at the Nairobi field meeting as an essential cross-cutting issue
which was largely omitted from the text. The redrafted manual
under consideration at the symposium went some way to rectifying
this situation, and the current working group was asked to review
the document and make recommendations for strengthening still
further the element of community participation. The 15 members
of the working group represented a range of NGOs, donor agencies,
UN agencies, field workers and the refugee community. The group
work started with reflection of the nature and scope of refugee
participation guided by a resource person from MSF Belgium.
In view of the limitation of time and the need to make
substantive inputs in the area of community participation, the
group decided to work, in the first instance, on defining
community participation and identifying related issues before
examining the draft manual to incorporate the subject throughout
the text. This report reflects this process and chapter-by-
chapter detailed editorial comments on the manual are presented
in Appendix 1. As the discussion evolved it was clear that the
group was normally speaking in very general terms about community
participation in refugee situations. These general reflections
were made directly relevant to the provision of a reproductive
health programme in the detailed comments on the manual itself.
The group's recommendations are included at the end of this
report. Examples of community participation in different phases
of the refugee process are included at Appendix 1.
Introduction to community participation
Defining community participation was not a simple task and
the literature was not found to be particularly helpful. The
group itself felt that community participation was an essential
part of the process of setting up appropriate, sensitive and
responsive reproductive health services in refugee situations. It
is important to recognize that community participation means
different things in different settings. The community itself
might be either the refugees or the host community. The style,
mode and nature of participation varies according to the phase of
the emergency as well as the culture of the population. The
acceptability and sustainability of programmes is dependent on
effective community participation. It is the only way of
ensuring "ownership" of programmes by the community and of
respecting democratic processes to at least a limited extent.
Community participation is an effective method of
emphasizing preventive measures in the domain of reproductive
health. Finally, community involvement is essential in order to
ensure that people get the services that they really need, rather
than simply those which others perceive are in their best
interests. This is an ongoing process which entails
understanding of cultures, support, training of refugees and
local staff, integration into the organizational framework of the
programmes and periodic evaluation of the impact of the
programmes by the refugees themselves.
a. Types of community participation
The following forms of community participation were
identified. It is not exhaustive, but offered a starting point
for a wide ranging debate:
* Labour Where refugees assist in planning implementation
and assessment either for salary,food or on a
voluntary basis.
* Resource Where refugees pay for services or take part in
any other cost sharing schemes. Resources may
also include information gathering such as
interviews and discussion groups.
* Individual Where the community appoints and supports
refugees to do certain tasks within the
programme.
* Community Here the activities are initiated by the refugees
themselves independent Initiatives of NGOS and
other international agencies.
* Programme Where representatives of the community take an
active part in setting Participation goals,
planning activities and monitoring and evaluation
of programme activities including self-help or
social support networks.
When defined broadly, participation may fulfil several
purposes, some of which may even contradict the original purpose;
i.e. participation may be used to legitimize existing gender
inequalities, hence we recommend that participation should be
undertaken with an understanding of the motives and objectives
and alternatives in each context. Given that reproductive health
touches on many important cultural and social traditions and
beliefs this transparency of motivation is necessary.
Realistically, empowerment in refugee settings is not a
spontaneous process and the support offered by international
organizations is crucial. However, there are several degrees
between refugee control and empowerment, including tokenism, as
well as outright manipulation.
The identification of these forms of community participation
resulted in the discussion of a number of controversial issues
such as payment for labour, the timing of participation, the
involvement of the local population, and the need for
coordination.
The question of payment for labour was to be viewed against
the need for long term sustainability and the community
eventually taking over its own running of programmes. The
imperatives of the emergency phase and the need for getting
programmes off the ground was considered a major obstacle in
getting the community to be motivated to give services free.
The converse was also true that refugees were very enthusiastic
to give their services in the emergency phase as they felt very
involved in helping each other. This enthusiasm often faded away
as their own survival needs surfaced in the subsequent months
when they realized that the solution to their problems was far
away. In the establishment of programmes it was important to
consider whose needs were being met - the agencies providing
services or the refugees. It is possible to use community
participation to manipulate outcomes in the interests of the
service providers rather than the refugees. Sustained refugee
involvement throughout the period of the operation probably has
to take the form of paid labour in order to ensure that the need
for paid employment and income generation was also met. The
group however did not come up with a clear prescription that
could be universally applied, but each situation had to be viewed
in terms of long term sustainability. The need for coordination
between NGOS was stressed in order that no unrealistic, unequal
and competitive levels of payment were established in the early
phases.
b. Timing of community participation
A matrix was presented to the group identifying the ongoing
stages of a refugee reproductive health programme namely,
assessment, planning, implementation and evaluation, during the
four phases of the refugee process, i.e. emergency, care and
maintenance, stabilization and repatriation. There was
considerable debate as to the realism of involving communities in
the planning and delivery of reproductive health services in the
early stages of the emergency. Most participants felt, however,
that such involvement could and should begin at the reception
centre, even if it only takes a very simple form, such as the
identification of traditional birth attendants or older women
who could assist in deliveries etc. prior to the setting up of
formal services. It was important to clarify levels and types of
involvement which could be used in achieving short as well as
long term goals. The group eventually gave very concrete
examples of how the community could be involved in the various
stages of assessment, planning and implementation of services.
These will be included as an appendix to this report.
While life saving activities are essential in the emergency
stage the quick delivery and organization of services should not
undermine the principle of involving the community as early as
possible. There was a clear tension between the need for quick
delivery of essential services which could result in a "top down"
approach and community involvement in assessment of needs for
which the community itself may not feel ready.
The short term goals should not undermine democratic
processes which are geared towards long term sustainability of
programmes.
UNHCR has developed a community response along with the
overall refugee emergency response. This involves the presence
of trained and experienced community workers from the outset of a
refugee emergency to assist the refugees identify their problems,
persons within the refugee community with skills and developing
structures which can be sustained over a period of time such as
refugee committees and developing a strategy of action which
involves refugee participation. This process takes approximately
3 months. Reproductive health can be part of the process. TBAs
and other paramedical health workers can be engaged from the very
outset in assisting the community to meet its reproductive health
needs particularly in the area of emergency deliveries and
assistance to cases of sexual violence.
Involvement of the local population
The question of involving the host community stimulated
considerable debate. For some agencies such involvement goes
beyond their mandate. However, the general feeling in the group
was that participation of the host community in the development
and maintenance of services was essential. The disparities
between well-served refugee populations and the host community
can lead to resentment if not violence. It was felt that refugees
should not be perceived as a privileged group and their impact on
the local environment should be kept to a minimum. It is
inevitable that they will make demands on local resources such as
district hospitals. While access of refugees to local health
facilities is negotiated with the local authorities the converse
should also be possible, namely, where separate services are
being provided for refugees in resource-poor areas consideration
should be given to offering open access to the local population.
It was recommended that donors and agencies should budget for
collaboration and strengthening of the local health system.
Collaboration among agencies
The sudden influx of large numbers of people from across
borders having a host of needs compounded by severe emotional
problems resulting from their experiences of loss and severe
violence, the host country residents often have anxiety and fears
relating to the presence of refugees among them. Governments
often go along with these fears and ensure that refugees are kept
cordoned off in separate locations. This aggravates the
prejudices that are there to begin with and often refugees are
blamed for everything that goes wrong in a locality. Negative
interactions between the local people and the refugees result in
a vicious circle of animosity which escalates over a period of
time.
It is therefore necessary to initiate dialogue and mutual
understanding and respect between the local community and the
refugees as early as possible in the refugee process.
In order for the participation of both refugee and host
communities to become an effective reality, mechanisms need to be
put in place from the time that an emergency is anticipated.
These should involve the host government, the international
agencies, the aid agencies and NGOs. Dialogue with the Ministry
of Health of the host country is essential prior to setting up
health systems for the refugees. The question which needs to be
asked is whether the host country has the capacity to manage the
refugees itself, rather than risk the creation of a 'country
within a country' with its attendant fears, resentments and the
possible development of a ghetto mentality. External support to
existing structures to cope with the additional load would
facilitate this process. It was considered that an integrated
approach to community participation would be best achieved if the
dialogue with the host country were conducted by the
international agencies (UNHCR) rather than bilaterally with each
interested party.
A further mechanism for coordination of initiatives in
community participation should be put in place at local level,
with the development of a consensus among the agencies regarding
their strategies. Within this framework, refugees should be
aware of and facilitate the solution of their own problems within
the context of the host country. Host countries themselves need
to develop mechanisms for participating in the aid offered to
refugees. This presupposes the development of mutual respect and
the elimination of fear and resentment through a process of
dialogue which offers information, communication and a sense of
shared responsibility.
Culture and gender
The twin concepts of culture and gender recurred throughout
the discussion on community participation in the development and
implementation of reproductive health programmes in refugee
situations. Culture, or the traditional way of looking at life
and doing things, is intrinsically interwoven into roles and
behaviour of the two sexes and affects perceptions and attitudes
towards reproductive health. Traditional ways of behaviour are
affected in refugee situations and changes are expected.
In situations where the population, largely women, have
experienced aggression and frequently sexual violence during the
emergency which disrupted their lives, they are often not able to
access health services because of cultural norms. Refugees,
especially women, are in a position of powerlessness and, once
within the camp, are frequently subject to further abuse, verbal
or physical, even at times from those with some responsibility
for protecting them. There is a need to create a climate within
the camp where such abuse is not tolerated and where the people
who have experienced it can seek support without fear of
stigmatization. In many traditional societies it is extremely
difficult for people to express their fears and anxieties when it
comes to discussing sexual matters.
Perceptions of reproductive health vary widely from culture
to culture and are an area requiring extreme sensitivity. Refugee
communities bring with them norms and values which may not
necessarily correspond with those of either the host community or
of the service providers. Episodes of sexual violence may trigger
the response of the sanctions required by traditional law of the
refugee community. It is vital that field workers acquire an
insight into the prevailing cultural norms of the refugee
population and that service provision is offered in a way that
respects the community's values, while supporting the principle
that the laws of the host country must be observed.
Aid workers must develop sensitivity to such cultural
inhibitions and work with leaders in the community to devise ways
of empowering women to seek what help they need.The presence of
an appropriate mix of males and females of various ages among
medical and paramedical staff and outreach workers would
facilitate access for both men and women.
Sustainability
While Community Participation is strongly supported in
principle, the real test is its sustainability over a period of
time, with long term involvement and responsibility for the
ongoing development of programmes without outside support and
continuous inputs. This has particular relevance to refugee
situations where dependency on outside help can be a major
hindrance to the development of initiative from within the
community if not initiated and deliberately worked at from the
outset.
One element that may help in this process is to identify
persons from within the refugee community as well as the local
community who possess the necessary skills and capabilities to
undertake responsibilities. It is also necessary to help them
adapt these skills to the situation, as it is compounded by
cross-cultural implications that may arise, as well as find ways
and means to adapt their previous knowledge to the current needs.
Training therefore has a very important place in community
work as it is a means to ensure that the people themselves are
involved in a thinking process about their own problems.
Outside technical experts can help them acquire new skills that
may be relevant to their situation. There is a need to transfer
technology and the current state of the art but with the proviso
that it is adapted to the culture and traditional norms of the
people. Change may take place as well but should be a gradual
process rather than the object of the exercise.
Some relevant components of such training would include
counselling skills for victims of trauma and sexual violence and
developing skills in needs assessment.
Summary
In summary, community participation:
* Requires active representation by women who have
traditionally been excluded from such roles in many
settings, including women not in traditional relationships
or unions.
* Is not a form of political control or reproductive control.
We must avoid passive or illusory representation that simply
continues to subordinate women.
* Requires credibility and confidence in the international
organizations that encourage it. Confronting potential
mistrust rather than avoiding it is a great challenge for
those working in the field.
* Is neither natural nor necessarily guaranteed, given that
refugees are highly traumatized or alienated and may
mistrust any forms of authority. Some people may not
respond to such invitations during different phases.
* Training of local and refugee staff is a vital component to
ensure sustainability.
Recommendations
1. Community Participation should be undertaken with an
understanding of the motives and objectives and alternatives
in each context.
2. Each situation should be viewed in terms of long term
sustainability. Coordination between NGOS is needed in
order that no unrealistic, unequal and competitive levels of
payment are established in the early phases.
3. The quick delivery and organization of services should not
undermine the principle of involving the community as early
as possible.
4. Donors and agencies should budget for collaboration and
strengthening of the local health system.
5. Dialogue aimed to achieve mutual understanding and respect
between the local community and the refugees should be
started as early as possible in the refugee process.
6. Dialogue to achieve an integrated approach to establishing
reproductive health programmes with the host country needs
to be conducted by the international agencies (UNHCR) rather
than bilaterally with each interested party.
7. Field workers must acquire an insight into the prevailing
cultural norms of the refugee population and ensure that
service provision is offered in a way that respects the
community's values and empowers women, while supporting the
principle that the laws of the host country must be
observed.
8. There should be of an appropriate mix of males and females
of various ages among medical and paramedical staff and
outreach workers to facilitate access and services for both
men and women.
*** These recommendation appear in the order in which they
feature in the text of the report and do not represent
an attempt at prioritizing.
Some examples of community participation
A. Emergency phase
In the Croatian emergency, on an island an hour's journey
from the mainland hospital, a refugee doctor who had only ever
practised research since qualifying found herself faced with a
woman in the late stages of labour. Understandably, she felt
extremely anxious and unable to cope adequately with the
situation. Suddenly she remembered the presence on the island of
a community of gypsies. They were certain to have among their
number women who were experienced in helping other women in
childbirth. Her guess proved right and a gypsy helped the woman
to give birth to a healthy baby boy, to the relief of all
concerned.
B. Stabilization
In the well established camp in NGARA, with a population of
half a million refugees, the refugee population was involved in a
successful Rapid Needs Assessment for STDs (sexually transmitted
diseases). The dimensions of the problem had to be established in
order to plan resource allocation, training, strategies for
service provision and measurement of impact of the intervention
after a three month period. Community leaders were invited to
select the zones and sectors for the study and to choose a
suitable site for a mobile clinic. In a number of cases they
offered alternative housing for the clinic.
Random selection of households for the study was done by the
community leaders blindfolding the fieldworkers and spinning them
around, then instructing them to walk between 50-100 steps,
select the fourth house on the left, where they would start the
household enquiry. Selection continued until each worker had
identified seven houses by this process and interviewed household
members between 15-54 years. Community workers were responsible
for the entire community sensitization which preceded the study
and which ensured its acceptance in such a sensitive area. The
involvement of the community throughout the process resulted in
the conviction that the study was theirs and therefore obtained a
far higher level of response than would otherwise have been
possible.
C. Care and maintenance
Refugees in India in the early 1980's were mainly young
Afghan men without family support. As numbers increased, access
to the local hospitals was arranged by the UNHCR office. In
order to facilitate proper use of the services interpreters, as
well as Medical Social Workers, were placed in these hospitals to
assist the refugees in explaining their problems to the doctors
and for the doctors to understand better the nature of the
refugees' problems.
The skin and VD department was much frequented and the
doctors soon sounded the alarm that the refugees, who were young
men mainly in the age range of 20 -35 years, were coming with
problems of repeated infection of venereal diseases. They were
moreover not completing their treatment and were sharing
prescriptions when their symptoms subsided. This created
immunity to the drugs which subsequently became ineffective.
This is a very traditional community. Matters pertaining to
sexual behaviour have to be dealt with in a sensitive and
discrete manner.
Closer understanding of the problems facing refugees
revealed that they also experienced great loneliness, isolation,
lack of support, frustration and a sense of anonymity which led
them to seek the company of prostitutes. Many of them were
spending the little money that was given them for their
subsistence on prostitutes from the local community.
Initially older men were asked to brief younger men on the
subject but soon this was found to be inappropriate as they were
either too shy to talk about the subject or were judgemental
about such behaviour. Younger men of the same age were then
involved in the process of briefing individuals who were found to
be VDRL +ve. These were mainly from the refugee community itself
and were persons who had been screened for their acceptance by
the community and were known for their neutrality and maturity of
outlook. They were given a brief training and orientation on the
medical aspects of the problem as well as the treatment involved
and the preventive nature of such work. They befriended
individuals coming to the clinic and provided valuable
information about the medical problems encountered.
Together with the individual work groups, refugees were
helped to discover other interests such as learning English,
playing football and doing other interesting things together such
as going for excursions and meeting with the local people
socially. The doctors at the clinic were further involved in a
more large scale community programme of explaining the evolution
of the diseases and the frightening nature of the last stages.
As the social aspects of the community developed the
incidence of cases at the clinic also seemed to stabilize and
even drop.The anonymity and loneliness and lack of normative
sanctions which often led to promiscuous sexual behavior now were
replaced by peer group pressures and personal responsibility. The
women from the local and refugee communities were indirectly also
helped.
===================================================================
ANNEX III
REPORT OF WORKING GROUP III
MINIMUM INITIAL SERVICE PACKAGE (MISP)
Chairperson: Dr. France Donnay (UNICEF, New York)
Resource Persons: Mr. William E. Brady (John Snow Inc.)
Dr. Carole Collins (Oxfam UK 1)
Rapporteur: Dr. Tine Duchausoit (MSF Belgium)
1. Introduction: concepts of the Minimum Initial Service
Package
MISP as a component of public health:
* a minimum package of services to cover a maximum of needs of
the population; coherent, integrated and global approach
* the objectives determine the activities to be carried out,
i.e. the services to be provided; these activities, in turn,
determine the contents of the package: material and human
resources (objectives -> activities -> contents)
* the workload should always be considered; if not, it is
impossible to achieve a coherent and global approach/package
* as much as possible: interactive (role of the population:
perceived needs vs. priority needs)
Things to consider:
* initial
* feasibility
* available resources (human, material, financial)
2. Discussion: MISP in refugee situations
What is initial?
The initial phase comprises both exodus and emergency phases
(see draft document of UNHCR for detailed description of these
phases and their characteristics). However, important
characteristics (shared by these two phases, so they can be dealt
with as one) to consider are:
* overall mortality and morbidity are usually high and
therefore will determine to the greatest extent what
services need to be provided (water, shelter, food, basic
curative care)
* no established/organized structures available to provide
services (at best, roadside tents for provision of basic
curative care)
* the available human resources are scarce (do no make
themselves known until their basic needs have been cared
for, no time for active search, other priorities)
* no extensive needs assessment has been done (might be under
way, but in any case results are not available)
What is MISP in relation to reproductive health in a refugee
setting?
The minimum initial service package is defined as the
reproductive health services that should be provided from the
beginning of a refugee situation and in any refugee setting.
To define the contents of the minimum initial service package in
the exodus/emergency phase of a refugee setting this must:
* respond to the overall need to reduce reproductive mortality
and morbidity; therefore the objectives/activities in terms
of reproductive health have to be seen within that framework.
Basically, this means addressing the curative needs of
deliveries, newborns, complications of abortions (hemorrhage
and infections). (So: both preventive and curative, but
curative should be stressed)
* provide good quality care: quality of services is essential
* consist of material that can be supplied in a "blind" way
(no detailed assessment needed, no specific training of
human resources needed for provision, no further detailed
knowledge of context). Therefore, one should mainly think
in terms of "lists" and "kits" as they are most adapted to
this kind of blind supply.
Taking into consideration the objectives outlined above, the
constraints mentioned, and considering what is feasible in the
initial phase, the following reproductive health activities are
essential (see table 1 below).
Objectives with regard to preventive and curative care during
different phases of a refugee situation
Exodus/emergency Stabilization/return
(initial assessment) (extensive assessment and
close, ongoing monitoring)
objective preventive care: objectives preventive care:
-reduce sexual abuse/violence -reduce sexual abuse/violence
-guarantee free access to condoms -guarantee free access to
-application of universal condoms
precautions against -application of universal
spread of HIV/AIDS precautions against spread of
HIV/AIDS
-guarantee access to family
planning services
-guarantee access to emergency
contraception
-optimal STD prevention
-guarantee that all blood
transfusions are safe
-guarantee access to
psychological support
and counselling (FP, sexual
violence, HIV,..)
curative services to be provided: curative services to be
provided:
-guarantee access to safe deli- -guarantee access to safe deli-
veries and care for the newborn veries and care for the new
-adequate management of complica- born
tions of abortions (hemorrhage -adequate management of compli-
and infections) cations of abortions(hemor-
rhage and infections)
-access to safe abortions (legal
context)
-provision of STD management,
including care for people with
HIV/AIDS
-support to victims of sexual
abuse
==================================================================
Preventive activities in initial phase:
OBJECTIVES ACTIVITIES INPUT
-reduce sexual -choice and design of -knowledge of
abuse/violence location to ensure environment
maximum safety
-guarantee free access -purchase, transport, -condoms in ade-
to condoms storage and distri- quate quantities
bution of condoms logistics chain;
staff and staff
training
-application of -purchase, transport, -WHO kit (con-
universal pre- storage and distri- tains all this
cautions against bution of gloves, already); staff
spread of HIV/AIDS disposable injection and staff
materials, sharp dis- training
posals, disinfectants
Curative activities in initial phase
OBJECTIVES ACTIVITIES INPUTS
-guarantee access to -identify referral -materials from
safe deliveries and points, organize UNICEF TBA/mid-
care for the newborn safe 24/24 hour wife kit and
transportation for from WHO emer-
referral; training gency kit
-adequate management of -identify referral -material from
complications of abor- points, organize UNICEF TBA/mid-
tions (hemorrhage and safe 24/24 hour wife kit and
infections) transportation for from WHO emer-
referral; training gency kit
===================================================================
Additional activities:
In addition to these specific activities and their inputs, the
following are necessary activities that will have an overall
effect:
* train staff of agencies involved to raise awareness of
reproductive health
* include data collection on reproductive health issues in
initial assessment procedures to enhance further planning
* assign responsibility for reproductive health to a specific
person in the team (without necessity of adding specialized
reproductive health staff at this stage)
3. Remarks that arose during the discussion
General
* One can have an effect on reproductive health, even if
nospecific reproductive health services are provided for in
theinitial phase: general services provided in the initial
phase do have an effect on reproductive health, e.g.
provision of adequate shelter (protection), water and
sanitation (infections)
* Given all the constraints, there is no choice but to make a
compromise between either being "quick" or "accurate"
* There is little idea about reproductive health mortality and
morbidity in refugee settings; more research is needed to
quantify this
Human resources
* Even if agencies are limited in what they can do as specific
reproductive health activities in the initial phase, it is
paramount that they are aware of reproductive health problems
* Human resources (both local and expatriate) available in the
initial phase are scarce and are busy with lots of other
activities; this is a crucial element to be considered.
Indeed, this has to be considered when assigning additional
tasks to these people: feasibility of workload, negative
effects on quality of other tasks being carried out
(eventually causing an increase in mortality/morbidity)
Material resources
* It seems that much is already provided for by existing kits
(WHO emergency kit, UNICEF TBA kit)
* Specific reproductive health material and supplies can be
incorporated into existing kits for emergencies. Condoms are
bulky to transport, therefore it is recommended that if they
are introduced into the WHO emergency kit, theybe put in
separate boxes
* Clear instructions should be included with the package
Instruments: one should consider their relatively high
cost, the differences existing between the different types and
the need for sterilization (in initial phase, not always feasible)
4. Closing remarks
It is obvious when talking about the minimum initial service
package, that other services should follow and this should be made
very clear in the manual, i.e. the minimum initial service package
is not a package standing on its own; therefore,a comprehensive
reproductive health package should be implemented following the
ongoing needs assessment.
The minimum initial service package should be implemented by
all agencies. However, even in the initial phase, organizations
can decide to add additional services (depending on the agency and
the resources at its disposal). For example, with regard to safe
deliveries, all agencies should identify referral structures and
organize safe referral on a 24-hour basis. If an agency is in a
position to provide extra services such as roadside or mobile
clinics to carry out deliveries, this can be done as well.
However, the latter is not part of the minimum initial service
package.
==================================================================
ANNEX IV
REPORT OF WORKING GROUP IV
INFORMATION, EDUCATION AND COMMUNICATION (IEC)
Chairperson: Ms. Beverly Tucker (Family Health International)
Resource Persons: Ms. Meena Cabral (WHO)
Ms. Marilyn Rice (WHO)
Rapporteur: Ms. Sara Townsend (UNHCR)
The group opened their session with a general discussion
about the meaning of Information, Education and Communication
(IEC) and its link to empowerment, mobilization and behaviour
change. It was agreed that "communication" is a two-way exchange
of information that implies understanding of information.
Applying that knowledge to one's own life is the first step to
behaviour change. To make IEC effective in the refugee situation,
we need to understand the audience and know the cultural context
(values, language, methods of communication).
Moving to a specific discussion of the draft Field Manual,
the group noted that field-testing of the manual and proper
training of field staff in its use will be key to ensuring the
effectiveness of this manual. The group suggested that the Manual
needed to make it more clear for whom it is intended and how to
use it. More discussion of how to tackle the problem of integration
of reproductive health care into other primary health care services
is needed.
There was consensus that the draft Manual was too specific
to refugee situations in Africa and less relevant to Europe, Asia
and Latin America. The group also agreed that the Manual was too
narrowly focused on refugees in camps as opposed to those in
integrated or hidden refugee-like situations.
Regarding IEC specifically, the manual should focus more on
"how to" guidance regarding design and implementation of IEC
programmes. It was noted that field managers are not necessarily
IEC experts and thus the manual should include a resource list of
instructional IEC materials. Each chapter could include three to
five examples of universal messages on that topic, as from "Facts
for Life".
After reviewing the IEC sections in each chapter of the
Manual (varying from one-line references to two-page detailed
explanations), the group decided to recommend that the IEC
sections in the various chapters be replaced by a reference to an
IEC annex, a comprehension treatment of the subject which would
include the material previously in the chapters. The contents for
this annex would be as follows:
I. Overview of IEC
II. Needs Assessment/Process/Program Development
- define target audience
- audience research (quantitative, qualitative)
- message development
- pre-test/revise/pre-test
- production/distribution/training
- evaluation
III. Counselling
- rights of clients/informed choice/quality of care
- role of counsellor
- characteristics of a good counsellor
- impact of values and attitudes on counselling
- verbal and non-verbal communication skills
- counselling techniques
- special populations
IV. Methods and Channels of Communication (advantages and
disadvantages)
V. Principles and Guidelines for Development of Essential
- process
- content
- creation of environment which encourages behaviour
change
- determination of channels of communication
VI. Resources
The group made the following suggested changes to the
Manual:
==================================================================
CHAPTER ONE: Reproductive Health in Refugee Settings
Introduce IEC as a cross-cutting topic and reference our
recommended Annex on IEC for additional information. Suggested
introductory section is as follows:
Information, Education and Communication activities,
including counselling, are crucial aspects of reproductive
health care and should be an integral part of services for
refugees. Simply making reproductive health services
available to women and men may not be enough.
Refugees, especially women, may face special circumstances
that makes it difficult for them to obtain the reproductive
health care they need even when it is available. Some of these
circumstances relate to the status of women in many parts of the
world. For example, they need consent of their husbands or other
members of their family. In some instances, the threat of domestic
violence may deter them from seeking care.
Other factors include religious and cultural beliefs, low
level of education (ignorance), fear of being judged, or expressing
personal concerns, perception of risk, and misperceptions about
reproductive health and family planning.
By recognizing and addressing such barriers to care health
providers can help women to get the help/services they need. By
providing accurate, appropriate information on their reproductive
health problems and empathetic counselling, providers can help
people make informed decisions about their reproductive health
given their circumstances.
Carefully designed print materials can be used to reinforce
the interaction between providers and refugees and help the
understanding of the health message, even for those with low
literacy levels. Use of mass media can also be an effective means
of raising awareness and disseminating important health
information/messages in refugee environments. Regardless of the
mechanisms used to deliver them, messages and health information
must be consistent, culturally appropriate and centred around the
real needs of refugees. Field workers and the refugees themselves
must be involved in developing the messages and materials to ensure
that the result is accurate, well understood and responsive to the
prevailing concerns (see Annex X for further information on IEC).
==================================================================
CHAPTER TWO: Advocacy
* Include mention of "schools" in this chapter as teachers play
a critical role in mobilizing a community where schools do
exist. It was mentioned that girls are often not in school.
* Increase "how to" components of advocacy (as is, the material
is too general and not practical)
* Discuss disadvantages of placing women in power positions
(such as food distributors): increased danger for women and
ill-effects on men who often are feeling a sense of
powerless and loss. Also, acknowledge the problem of having
refugee men "recruit" the women leaders. Often this role is
given to those women who have provided sexual favours for the
men. Perhaps using women to do the recruitment might be one
way to lessen the risk of women in leadership roles.
* Emphasize the influence power of traditional and religious
leaders. Also, acknowledge the powerful effect that some
political or religious figures outside of the refugee
community may have within the refugee group.
==================================================================
CHAPTER THREE: Violence
* Emphasize the need to support counsellors who are working with
victims of violence (who often suffer "secondary trauma").
* Acknowledge that we are promoting behaviour change, which
could be seen as not "respecting" or being "sensitive" to the
culture (when, for example, we seek to decrease FGM incidence)
* Provide more concrete examples of safety measures for
protecting women and men.
==================================================================
CHAPTER FOUR: Adolescents
* Define target group. Some cultures do not consider young girls
as adolescents if they are married. Perhaps it would be useful
to distinguish between girls and boys given their vastly
different experiences. The issue of whether children younger
than adolescents should be targeted as well was debated.
* Question: should we as a group encourage the host country to
develop schools for the refugees and then encourage girls to
attend? Given the few numbers of schools, play and work sites
may be more likely opportunities to reach youth.
* Include mention of the creativity and influence power of youth
on adults and the ability of youth to take active part in
needs assessments, defining problems and designing solutions.
In Chapters Five, Six and Seven (Safe Motherhood, Family Planning
and STDs), remove sections on IEC and replace with a reference to
IEC Annex.
======================================================================
CHAPTER EIGHT: Assessment
* Move location of chapter to follow Chapter One.
* Include more material on qualitative research tools.
* Rewrite to be more instructional. Include samples of data
collection forms or charts (for both reproductive health as a
separate and an integrated programme) along with explanation
of how to use these tools. [CDC and UNICEF's Emergency Manual
have some simple examples.]
The group made the following comments regarding the format of the
Manual:
* Divide Manual into two sections (the first presented in
bullet-like format similar to FACTS FOR LIFE; the second one
providing more detail but still presented in simple,
instructional style).
* Use binder to facilitate updating and tailoring for
various situations. Do not make the final version too
slick/glossy.
* Make style and format more engaging for field workers.
=================================================================
ANNEX V
REPORT OF WORKING GROUP V
HUMAN RESOURCES FOR REPRODUCTIVE HEALTH TRAINING
Chairperson: Dr. Hedia Belhadj-El Ghouayel (UNFPA HQ)
Resource Person: Dr. Genevive Begkoyian (UNHCR, Zaire)
Rapporteur: Ms. Nancy Pendarvis Harris (John Snow Inc.)
The group discussed issues pertaining to comprehensive human
resource development programme in reproductive health in refugee
settings.
The group felt that at the outset and before initiating
programme design, a few questions needed to be answered. These
include: what are the beset ways to identify the staff to be
trained and that will be useful to assist in the camp; what are
the practical measures taken to train them? Who will coordinate
the training? Who will define the job descriptions? To evaluate
the training, indicators were to be selected very early and
should include equality indicators.
Owing to the scarce resources and shortages in financial aid
in general, and in the context of conflict-stricken areas in
particular, careful needs assessment, monitoring and evaluation
are essential for optimizing the utilization of both human and
financial resources. A needs assessment should always precede
programme design even though some activities may be initiated
while the results of a more comprehensive assessment exercise are
awaited. The assessment should indicate the qualifications of
human resources available in the camps or in the vicinity among
host-country health structure, the qualifications of the staff,
and therefore their needs for further training. The persons
identified for training should participate in identifying these
needs. A careful gender distribution among all categories of
staff should be maintained.
Training should be timely, role-appropriate, skill-based,
participatory and geared towards problem-solving methods. It
should also include mechanisms for self-assessment as well as
opportunities for retraining. the topics should encompass the
comprehensive array of reproductive health components. An
integrated approach to reproductive health within primary health
care, from the outset, is the most efficient way to provide skill
development. Technical skills and inter-personal communication
and counselling skills, gender awareness, awareness on human
rights including humanitarian law, protection issues pertaining
to sexual violence should be included. All managers, clinic-based
(doctors, midwives, nurses and front line staff) and community
health personnel (community health staff, traditional birth
attendants and traditional healers), community leaders and
community group representatives, including women's groups when
applicable. Other categories of camp staff, such as those
responsible for aid relief distribution as well as community
workers, including security and protection personnel should
undergo orientation.
In addition, advocacy for the issues of concern cannot be
efficient if country officials and programme assistants involved
with coordination and/or implementation of aid relief programmes
do not have a good understanding of the issues at stake and are
not committed to them. These agency personnel (NGOs and
international agencies personnel) should receive training on the
same topics as mentioned above, during emergency preparedness
training, as well as skills for budgeting and target-costing and
logistics management and procurement procedures.
The appointment of a reproductive health coordinator to
assist, when the size of the refugee population justifies it. The
Primary Health Coordinator would mobilize the necessary efforts
for service-delivery as well as for supervision and training. The
reproductive health coordinator would then play a role in
coordinating community workers activities, and in ensuring
supervision and conducting retraining. He/she would also play an
advocacy role in reproductive health and provide advice to
community members.
The following matrices discussed during the working group
session and finalised by Ms. Rikka Trangsrud, FCI, summarise
selected training needs by category of staff:
==================================================================
REPRODUCTIVE HEALTH IN REFUGEE SITUATIONS: TRAINING AND HUMAN
RESOURCE REQUIREMENTS
FRAMEWORK TRAINING REQUIREMENTS
Relief Workers: All managers should have a basic
Including Headquarters staff, understanding of reproductive
UNHCR & NGO health issues, and a comprehen-
Programme Manager, Protection sive understanding of gender
Officers and human rights issues.
Protection officers in
particular should have a
comprehensive understanding of
issues of violence and skills in
communication and counselling.
Host country representatives: Health care personnel from host
Including Health care personnel, countries should have skills in
Police, Information Officers providing reproductive health
care, communication and
counselling, and a basic
understanding of gender and
human rights issues.
Police and Information Officers
should have a comprehensive
understanding of human rights
issues, and a basic under-
standing of gender and repro-
ductive health.
Health care providers: Health care providers at all
Including physicians, levels must have skills in the
nurses/midwives, frontline health provision of reproductive
workers, community health workers, health, and in communication
TBAs: and counselling according to
locally and internationally
established guidelines. They
should have a comprehensive
understanding of gender and
human rights issues, and a basic
understanding of assessment,
monitoring and evaluation.
The Reproductive Health
Coordinator should have
management skills, including
assessment, monitoring and
evaluation, as well as a
comprehensive understanding of
reproductive health, gender and
human rights.
Social service providers: Social service providers should
Including social workers, be skilled in ommuncation and
interviewers, counsellors, counselling, with basic under-
teachers standing or reproductive health
and a comprehensive under-
standing of gender and human
rights.
Community members: Key community leaders should
Including leaders of women's have a common understanding of
and adolescent groups reproductive health, gender and
human rights, as well as basic
skills in assessment, monitoring
and evaluation.
==================================================================
SELECTED TOPICS FOR TRAINING AND
HUMAN RESOURCE REQUIREMENTS
HEALTH COMMUM GENERAL HUMAN
FRAMEWORK CARE & AWARE- RIGHTS
SKILLS COUNSEL NESS
Sexual & Institutional staff:
gender Headquarters staff, 2,4 2,4 2,4 2,4
violence Programme managers, 2,3 2,4 2,3 2,3
Reproductive health 2,3 2,4 2,3 2,3
coordinators
Clinical staff:
Physicians 1,3 1,3 3 3
Nurse/Midwives 1,3 1,3 3 3
Frontline health
worker 1,3 1,3 3 3
Social ser-
vices/security:
Counsellors 4 1,3 3 3
Social workers 4 1,3 3 3
Security officers 4 4 4 4
Teachers 4 4 4 4
Refugee community:
Health Worker (CHW, TBA) 4 4 4 4
Community leaders 4 4 4 4
Family International staff:
planning Headquarters staff 4 4 4
Programme managers 2,4 2,4 2,3
Repro. health co-
ordinators 2,3 2,3 2,3
Clinical staff:
Physicians 1,3 1,3 3
Nurse/Midwives 2,4 1,3 3
Frontline health
workers 2,3 3 3
Social ser-
vices/security:
Counsellors 4 3 4
Social workers 4 3 4
Security officers 4 4 4
Teachers 4 4 4
Refugee community:
Health worker(CHW, TBA)1,3 1,3 4
Community leaders 4 4 4
1= skill-oriented, 2= management oriented, 3= comprehensive
understanding, 4= basic understanding, 5= none required
==================================================================
ANNEX IV
REPORT OF WORKING GROUP VI
DRAFT FIELD MANUAL
Chairperson: Dr. Serge Mal (UNHCR)
Rapporteurs: Ms. Corinne Packer (UNHCR)
Mr. Chris Brazier (New Internationalist)
The Chairperson of the Working Group opened the discussion
by welcoming the participants who had elected to join this
working group, the aim of which was to review the content of the
chapters forming the "draft field manual". He began the
discussions by giving a brief summary of the activities leading
up to the present draft field manual and suggesting that the
group work on a chapter-by-chapter basis, starting with the
introduction.
Before beginning a detailed review of each chapter, Dr. Mal
reminded the group of two essential points: a) that the comments
and suggestions made during the field testing of the draft manual
in Nairobi should always be borne in mind; and b) that the
ultimate goal of the group was to ensure that the manual is a
practical tool.
The first task at hand was to define more clearly the target
audience of the Field Manual. The group agreed that field
programme managers would be the primary target users (or at a
minimum "handlers"). Each manager would thus possess a manual, be
familiar with its contents, and be responsible for distributing
the essential information to the appropriate personnel so that
these could oversee the implementation of different aspects of a
reproductive health programme for which they would be qualified.
General chapters, unlike those addressed to personnel possessing
a certain level of medical knowledge, could be used more broadly
by various field personnel.
1. Introduction
The group agreed that the initial chapters of the manual
were somewhat lengthy and could cause the used to lose interest.
It was thought that the crux of the problem and the ways in which
it could be resolved should be stated more clearly and in simple
terms. Bearing this in mind, the group decided it would be best
to merge the first four sections of the manual (the preface,
introduction, Chapter I and Chapter II) into a concise
introduction.
2. General Structure and Presentation of Chapters III to VIII
A number of issues on the general content and presentation
of the technical chapters in the manual were discussed. It was
decided that "general" chapters would follow a similar structure
as best as possible. A suggested structure consisted of the
following sections: introduction (containing a rationale and
objectives), preliminary considerations, interventions/
implementation, and monitoring and evaluation. An important
recommendation coming out of the Nairobi field testing was that a
list of suggested reading materials related to the chapters be made
available. The group, therefore, took special care to ensure such
a list would appear at the end of each chapter where possible.
3. Specific Content of Chapters III to VIII
The remainder of the morning, afternoon and evening was
spent in a detailed review of each of the technical chapters in
the manual. Additions, modifications and deletions were discussed.
Where consensus was achieved, notice was made to ensure that the
suggested changes will be incorporated in the following "revised"
draft of the manual.
==================================================================
ANNEX VII
REPORT OF THE AD HOC WORKING GROUP
ON IMPLEMENTATION
Members
Willa Pressman, USAID
Rashim Ahluwalia, IRC
Carol Djeddah, WHO/FHE
Kirsi Madi, UNICEF
Yvette Stevens, UNHCR
Cate Johnson, USAID
Helen Young, Marie Stopes International
Overarching goal
Implement and integrate reproductive health into
refugee situations (5 year time-frame).
Short-term goal
Finalise and operationalise the Reproductive Health
Field Manual in as many refugee situations as
possible (2 year time-frame).
Symposium goal
1. Revise Reproductive Health Field Manual
2. Build advocacy for support of reproductive health activities
in refugee situations.
Next steps
1. Finalising and operationalising the Field Manual.
a. Inter-Agency Working Group (facilitated by UNHCR)
finalises the Plan of Action for implementing the Manual.
This Working Group would meet at discrete points in time;
their scope of work would include:
* Manual distribution and guidance in use;
* Institute a training plan for each level of provider(CHW,
clinician, general field staff);
* Obtain feedback from field sites;
* Review feedback and incorporate into Manual;
* Ensure that all parts of the Manual are tested,
monitored, and evaluated in a variety of settings
Identify test sites, if necessary:
* Establish time-frame, targets, and indicators for
evaluation;
* Address logistics: a firm system of procurement and
supply needs to be established and rigorously followed.
Considerations for logistics include quality,
time-frame for distribution, procurement, and cost.
A person will be seconded to UNHCR and assigned to oversee
this task.
b. A WHO Consultative Working Group on reproductive health
will compile Reproductive Health Technical Guidelines for
populations in transition. The WHO Working Group will be
linked to the Inter-Agency Working Group and collaborate on
both the Field Manual and Technical Guidelines.
2. Build internal and external advocacy
Internal advocacy will be strengthened by participants
within their own organisations, orienting:
* Governing Board
* Organisation at large
External advocacy will be achieved, ensuring that additional
resources are secured to support reproductive health activities.
Donor advocacy and coordination will be addressed through:
* UNHCR Annual Executive Meeting;
* DHA Inter-Agency Standing Committee;
* Individual advocacy with donors;
* Advocacy with affected countries.
A donor meeting may be necessary to discuss the need for
implementing the reproductive health agenda and to secure
additional resources.
3. Initative for other emergency-affected populations
Develop a distinct, additional initiative to implement all
aspects of reproductive health in the following settings:
* Internally-displaced persons
* Migrants
* Emergency situations in general, including local populations.
This necessitates designating a focal point (organisation,
person(s)) to coordinate this effort.
==================================================================
ANNEX VIII
AGENDA FOR THE SYMPOSIUM
WEDNESDAY 28 JUNE 1995: Plenary session at the Palais des Nations
OPENING SESSION AND PANEL DISCUSSIONS
09:00 - 10:00 Registration
10:00 - 10:15 Opening of the meeting, adoption of the agenda and
statement by Dr. Nafis Sadik, Executive Director,
UNFPA
10:15 - 11:00 Statements by:
Dr. Hu Ching-Li, Assistant Director-General, WHO
Mr. Christian Voumard, Senior Advisor, Health,
UNICEF
Dr. Tine Dusauchoit & Ms. Patricia Hindmarsh, NGO
representatives
Dr. Ljiljana Kordic, refugee representative
Mr. Gerald Walzer, Deputy High Commissioner, UNHCR
11:30 - 13:00 Panel discussion 1: "Making reproductive health
activities a reality in refugee situations" -
Moderator: Dr. France Donnay, UNICEF
* Overview: Dr. Tomris Trmen, WHO/FHE
* NGO experience in the introduction of Reproductive
Health Services: Dr.Peter Poore, SCF/UK
* Special Challenges in Reproductive Health:
Ms. Barbara Smith, IRC
15:00 - 16:30 Panel Discussion 2: "Legal, ethical and human rights
issues on Reproductive Health in refugee situations"
- Moderator: Ms. Ann Howarth-Wiles, UNHCR
Panelists: Ms. Karin Landgren (UNHCR)
Dr. Doris Schopper (WHO)
Mr. Guy Goodwin-Gill (Faculty of Law,
Amsterdam)
17:00 - 18:00 Presentation of draft "Field Manual" and preparation
of Working Group discussions: Dr. Serge Mal, UNHCR
=================================================================
THURSDAY 29 JUNE 1995: UNHCR building, rue Montbrillant
TECHNICAL DISCUSSIONS
09:00 - 16:00 Working group discussions:
Group 1: Integration of RH services into existing
programmes for refugees
Group 2: Community participation
Group 3: Minimum Initial Service Package (human
and material resources to be mobilized
as early as possible in a refugee
situation: kits & early initial
activities)
Group 4: Information, education, communication
Group 5: Human resources for reproductive health
and training
Group 6: Draft "Field Manual"
Group 7: Implementation
16:00 - 17:30 Preparation of discussion summaries by Chairpersons
and Rapporteurs for presentation to plenary session
on 30 June.
==================================================================
FRIDAY 30 JUNE 1995, Palais des Nations
PLENARY SESSION, MAIN CONCLUSIONS AND RECOMMENDATIONS
09:00 - 12:30 Presentation of Working Group reports
14:30 - 16:00 - Adoption of Recommendations
- Follow-up activities
Official Closure: Mrs. Sadako Ogata, United Nations High
Commissioner for Refugees
==================================================================
ANNEX IX
LIST OF PARTICIPANTS
1. Countries/Permanent Missions
Croatia Dr. Tanya Vucelic
France Ms. Emmanuelle Mitte
Germany Dr. Birgit Niebuhr, GTZ
Italy Ms. Ginevra Letizia
United Kingdom Ms. Sharon Wilkinson, ODA
United States of America Ms. Artificio-Rogers
Ms. Kelly Tallman Clements
Ms. Cate Johnson
Ms. Katherine Perkins
Ms. Willa Pressman
2. NGOs
Action internationale contre la faim Dr. Philippe Leborgne
Anti-racism Information Service Ms. Elisabeth Bumgarner
CARE Ms. Judy Benjamin
Mr. Carlos E. Cardenas
Ms. Jane Exener
Ms. Joan Schubert
Family Care International, Kenya Ms. Rikka Trangsrud
Family Health International Ms. Beverly Tucker
Inter-African Committee, Switzerland Ms. Yvonne Von Stedingk
International Babyfood Action Network Ms. Nancy-Jo Peck
Ms. Judith Philipona
International Catholic Migration
Commission Ms. Homayra Etemadi
International Rescue Committee Ms. Barbara Smith
Ms. Monica Corish
International Working Group on Ms. Elizabeth Janz
Refugee Women Mayer-Rieckh
IPAC-Flemish AIDS Coordination Centre Ms. Dominique Caplin
International Planned Parenthood Ms. Sara Butterfield
Federation Dr. Pramilla Senanayake
Mdecine francophone Afrique, France Dr. Alexandre Boskowitz
Mdecins sans frontires Dr. Tine Dusauchoit,
Belgium
Ms. Lucie Blok, Netherlands
Dr. Enric Freixa, Spain
Dr. Marie-Paule Lung Yut
Fong and Mr. Robert
Muller, MSF
International
Andrew Mellon Foundation Ms. Samantha Wheeler
Oxfam Dr. Carole Collins
Refugee Policy Group, Switzerland Ms. Letitia van Drunen-van
Haaren
Save The Children Fund, UK Dr. Peter Poore
John Snow Inc. Mr. William E. Brady
Ms. Nancy P. Harris
Mr. Peter Wondergem
Marie Stopes International Ms. Patricia Hindmarsh
Dr. Ljiljana Kordic
Ms. Frances Stevenson
Ms. Helen Young
World Association of Girl Guides
& Girl Scouts Ms. Celia Griver
Ms. Cosette Menzies
Ms. Bernadette von der Weid
==================================================================
3. Universities, Training Centres, Hospitals and Research Centres
African Medical & Research Foundation,
Tanzania Mr. Wences Msuya
Centre for Disease Control and
Prevention, Atlanta Ms. Judith Moore
Columbia University Dr. Richard Neugebauer
Ecole nationale de la sant
publique, Rennes Dr. Alain Jourdain
Faculty of Law, Amsterdam Mr. Guy Goodwin-Gill
Harvard University Dr. Ritu Sadana
Hpital Broussais Dr. Elisabeth Aubeny
Swiss Federal Institute of Technology Mr. Dominique Hausser
Washington College of Law Ms. Lauren Gilbert
4. Independent Experts
Dr. Leila Mehra
5. Observers and Private Companies
Azco Nobel (Organon) Mr. R. Loohuys
New Internationalist Mr. Chris Brazier
6. International Organisations
International Federation
of Red Cross and Dr. Rashim Ahluwalia
Red Crescent Societies Dr. Alireza Mahallati
Dr. Hakan Sandbladh
International Organization
for Migration Dr. Paola Bollini
Dr. Manuel Carballo
Mr. Peter Schatzer
Dr. Harald Siem
World Health Organization Dr. Hu Ching-Li
Dr. Tomris Trmen
Dr. Agostino Borra
Dr. Mark Belsey
Mrs. Meena Cabral de Mello
Dr. Jos de Cods
Ms. Helen Davis
Dr. Carole Djeddah
Dr. Gilles-Bernard Forte,
Zagreb
Dr. A. Friedman
Dr. Peter Hall
Mr. Hans V. Hogerzeil
Dr. Susan Holck
Dr. Q. Monir Islam
Mr. Kanokporn Kaojaroen
Ms. Malika Ladjali
Dr. Suman Mehta
Dr. G. Ogbaselassie
Ms. Marilyn Rice
Dr. Helen Schneider
Dr. Doris Schopper
Sister Anne Thompson
7. United Nations
UN Centre for Human Rights Ms. Maarit
Kohonen UN Department of Humani-
tarian Affairs Mrs. Anne Dawson-Shepperd
UNDP New York Ms. Laetitia Atlani
UNFPA Dr. Nafis Sadik, New York
Mr. Jyoti Singh, New York
Dr. Hedia Belhadj-El
Ghouayel, NY
Mr. Roushdi El-Heneidi,
Geneva
Dr. Hans de Knocke
Dr. Bill Musoke, Tanzania
Mr. Elisa Muhingo, Tanzania
Dr. Daniel Pierotti, Geneva
Ms. Mari Sasaki, Geneva
UNHCR Mrs. Sadako Ogata
Mr. Gerald Walzer
Mr. Franois Fouinat
Dr. Mohamed Qassim,
Bangladesh
Dr. Genevive Begkoyian,
Bukavu
Dr. Claire Bourgeois, Goma
Ms. Rosalud de la Rosa,Goma
Dr. Babu Swai, Kenya
Dr. Alvaro Alonso, Karagwe
Ms. Julie Bissland
Ms. Rita Bhatia
Dr. Mohamed Dualeh
Ms. Ann Howarth-Wiles
Ms. Karin Landgren
Ms. Marie Lobo
Dr. Serge Mal
Ms. Ruth Marshall
Mr. Nicholas Morris
Ms. Corinne Packer
Ms. Gloria Sagarra
Ms. Yvette Stevens
Ms. Sofie von Stapelmohr
Ms. Sara Townsend
(consultant)
UNICEF Dr. Christian Voumard
Dr. France Donnay
Ms. Brigitte Duchesne
Ms. Kirsi Madi
Mr. Mitshidiso Moeti
UNNY - Population Division Ms. Susan Pasquariella
UNOG - Office of the Director-General Mr. Serguei Khmelnitski
UN Volunteers Ms. Almaz Gebru
World Food Programme Mr. Bernd Kss
Mr. Bhim Udas