Evaluation of the Implementation of the Minimum Initial Service Package (MISP) for Reproductive Health among Syrian Refugees in Irbid City and Zaatri Camp, Jordan

Conducted by the Inter-agency Working Group on RH in Crises

Sandra Krause/Women’s Refugee CommissionHolly Williams/CDCSamira Sami/CDCMonica Onyango/Boston UniversityWilma Doedens/UNFPA* Basia Tomczyk * Seven local staff

MISP Evaluation: Objectives Assess the extent to which MISP has been

implemented in Irbid City and Zaatri Camp. Identify the availability, accessibility, and use

of MISP services. Describe facilitating factors and barriers to

the implementation of MISP services.

MISP Evaluation Inter-agency preparatory work Institutional Review Board (Human Subjects

Protection) approval by CDC Field work: 17 – 21 March 2013 Mixed methods

Key informant interviews Health facility assessments Focus group discussions

Context 355,493 Syrian refugees in Jordan

o 298,025 registeredo 57,468 unregistered refugees in urban areas

164,365 Zaatri camp 133,660 Urban areas

o 15.8% in Irbid City (n=47,087) o 13.2% in Amman

Ongoing humanitarian crisiso ~1,500/day influx

Context Specific to Irbid City

• Ministry of Health• Non-governmental organizations

Credit: UNFPACredit: Sandra Krause/WRC

Credit: Sandra Krause

Credit: Jeff J Mitchell/Getty Images, The Guardian

Context Specific to Zaatri Camp

• High level of medical care.• Low level of community engagement and

primary health care.

Credit: UNFPA

MISP Objectives1. Ensure the health sector/cluster identifies

an organization to lead implementation of the MISP.

2. Prevent and manage the consequences of sexual violence.

3. Reduce HIV transmission.4. Prevent excess maternal and newborn

morbidity and mortality.5. Plan for comprehensive RH services as the

situation permits.

Additional priorities of the MISP Ensure contraceptives are available to meet

the demand. Ensure treatment of sexually transmitted

infections (STIs) is available. Ensure antiretrovirals (ARVs) are available to

continue treatment for people already on ARVs including for prevention of mother to child transmission.

Distribute culturally relevant menstrual protection materials to women and girls.

Methods Key informant interviews (11) + 6 o Health and RH managers, coordinators

directors o MOH, UN agencies, NGOs Health facility assessmentso Zaatri camp (5 including: 2 hospitals; 1 health

center; 2 clinics) + referral hospitalo Irbid city (7 including: 2 hospitals; 2 health

centers; 2 clinics; and 1 blood bank)

Methods Continued Focus group discussions (Syrian women 18-49

years)

Assess attitudes and knowledge about RH and access to services

o 101 women in Zaatri campo 58 women in Irbid City

Findings related to the MISP

1) Coordination of the MISP• Lead RH organization (MOH/UNFPA)• Designated RH officer for the emergency• RH Coordination meetings • Funding and supplies (RH Kits)

2) Prevent and manage sexual violence• Camp: inadequate lighting in camps and

distance to services. Urban: distance to schools.• Limited availability and knowledge of clinical

services.

Findings related to the MISP (cont)

3) Reduce HIV Transmission• Safe blood transfusion.• Standard precautions are generally in place.• Condoms available but access is restricted.

4) Prevent maternal and newborn morbidity/mortality• Skilled birth attendants are available.• Basic/Comprehensive emergency obstetric and

newborn care available.• 24/7 referral services established but limited.• Negative perceptions by community of health

services.• Distribution of clean delivery kits not

implemented.

Findings related to the MISP (cont)

5) Planning for Comprehensive RH Services• Gap in background data for RH.• Sites for future RH services are in process.

6 ) Additional Priorities• Strong desire for family planning: generally

available for married couples. • Lack of protocols for Clinical Care for Survivors

and STI care.• ARVs very limited.• Gap in menstrual hygiene supplies.

Priority Concerns of Refugee Women and Girls in Zaatri Camp• Desire to be treated with dignity and respect.• Hygiene

o Toilets: maintenance, not sex-specific.o Lack of clean water.o Major desire for hygiene and cleaning products.

• Inequitable distributions.• Lack of supervision of community/street

leaders.• Strong perception of no outreach from

agencies.• Inability to work or volunteer.• Reported increase in domestic violence.

Priority Concerns of Refugee Women and Girls in Irbid City

• High rent and utility costs.• Inability to work.• Inequitable distribution and need for UN

supervision.• Strong need for UN card to improve quality of

life.• More flexibility related to purchases with

vouchers.• Strong tensions with host community.

Key Facilitating Factors to MISP Implementationo Government of Jordan’s pre-existing level of infrastructure, health care system and willingness to address RH among Syrian refugees

oDedicated lead agency and RH focal point in the health sector

o Adequate RH materials and supplies

o Donor support for the MISP

oCapacity Development through prior MISP training’s

Key Barriers to MISP Implementation

o Lack of adequate focus to urban areaso Lack of adequate staff in urban areas

o Lack of protocols for care for survivors of sexual violence and sexually transmitted infections.

o Limited community outreach

o Lack of sufficient funding; limited supplies distribution

Limitationso Cross-sectional – limits comparison to different points in time

oContext of an ongoing emergency with large influxes to study areas

o Challenges with KII and Health Facility Study tools.

o Lack of experience of data collectors and time to train them

o Participants chosen by NGO staff did not always meet age inclusion criteria

Conclusion: Progress and GapsProgress Health and RH directors, managers and coordinators were largely

knowledgeable of MISP objectives and priority activities

MISP services and key elements to support implementation of the MISP were largely in place, including a dedicated lead agency to support MISP implementation within the health sector, a focal point for RH coordination, regular RH coordination meetings in Amman and Zaatri camp, and RH kits and supplies, and funding for MISP implementation.

Lead agencies (MOH; UNHCR and UNFPA) in health and reproductive health demonstrate concerted effort to address the MISP and CRH.

Conclusion: Progress and GapsGaps Urban areas received less attention in coordination

initiatives along with reported challenges in human resource capacity.

Health and RH directors, managers and coordinators had very limited understanding of the additional priorities of the MISP.

Women and girls were dissatisfied with the quality of care in Zaatri camp.

Conclusion: Progress and GapsGaps Clinical care for survivors of sexual violence was very

limited : Women and girl’s and service provider’s knowledge of these services were low.

Lack of basic necessities including sanitation supplies. Gap in provider and beneficiary interface e.g. lack of

community engagement and information sharing; poor provider-client interactions

Contingency plans were developed but not activated. Gap in systematic RH indicator collection at facilities

in Zaatri

Acknowledgements Jordanian Ministry of Health UNHCR UNFPA IRC Jordanian Women’s Union Gynecologue Sans Frontieres

(GSF) Royal Medical Services (RMS) Jordan Health Aid Society

(JHAS)–Women’s Clinic Physicians Across Continents

(PAC) Moroccan Field Hospital (MFH) Marfraq Hospital

IFH Noor Al Hussein Foundation Amman Jordan Association IMC MDM Medair UNAIDS International Relief &

Development WHO Save the Children MISP Evaluation Translators

Thank You!

Recommendations Scale up efforts to ensure basic needs for

reproductive health are being met through the provision of hygiene products.

Implement safety measures to protect women and children from violence, such as safe transport to schools in Irbid City and adequate lighting and sex-specific latrines in Zaatri Camp.

Scale up the availability of care for survivors, particularly in urban areas and that all health care providers and protection staff are informed about the availability and location of care for survivors.

Recommendations (cont) Develop culturally appropriate mechanisms for

improving knowledge about the benefits of seeking care and available clinical services for survivors of sexual violence.

Undertake culturally appropriate methods to inform the community of where to access free condoms and other forms of family planning.

Ensure the availability of and access to emergency obstetric and newborn care 24 hours a day, seven days a week.

Next Steps

Global evaluation: advocate findings in advance of:o International Conference on Population and

Development (ICPD) + 20o Millennium Development Goals (MDGs)

Develop beneficiary and field partner reports.