Chapter 1
The Minimum Initial Service Package (MISP) for Reproductive Health

GOAL   The goal of the MISP is to reduce mortality, morbidity and disability among populations affected by crises, particularly women and girls. These populations may be refugees, internally displaced persons (IDPs) or populations hosting refugees or IDPs. OBJECTIVES and ACTIVITIES   1.   Identify an organization(s) and individual(s) to facilitate the coordination and implementation of the MISP by: ensuring the overall RH Coordinator is in place and functioning under the health coordination team; ensuring RH focal points in camps and implementing agencies are in place; making available material for implementing the MISP and ensuring its use. 2.   Prevent sexual violence and provide appropriate assistance to survivors by: ensuring systems are in place to protect displaced populations, particularly women and girls, from sexual violence; ensuring medical services, including psychosocial support, are available for survivors of sexual violence. 3.   Reduce the transmission of HIV by: enforcing respect for universal precautions; guaranteeing the availability of free condoms; ensuring that blood for transfusion is safe. 4.   Prevent excess maternal and neonatal mortality and morbidity by: providing clean delivery kits to all visibly pregnant women and birth attendants to promote clean home deliveries; providing midwife delivery kits (UNICEF or equivalent) to facilitate clean and safe deliveries at the health facility; initiating the establishment of a referral system to manage obstetric emergencies. 5.   Plan for the provision of comprehensive reproductive health services, integrated into primary health care (PHC), as the situation permits by: collecting basic background information (see Appendix A on monitoring and evaluation); identifying sites for future delivery of comprehensive RH services; assessing staff and identifying training protocols; identifying procurement channels and assessing monthly drug consumption.

What supplies are necessary to implement the MISP and where can an agency get them?

The MISP includes a pre-packaged set of kits containing drugs and supplies aimed at facilitating the implementation of priority RH services in the early phase of a crisis. UNFPA is in charge of assembling and delivering these RH Kits. As logistical problems are common in crisis settings, agencies should prepare by including RH supplies within their overall medical supply procurement. Please see Chapter 7 for more information on ordering supplies.

Why is the MISP a priority?

While resources should not be diverted from dealing with other major health threats, implementing the MISP is essential to reducing mortality and morbidity experienced particularly by women and girls. There are multiple competing health priorities in an emergency, such as addressing diarrhea, measles, acute respiratory infections, malaria and malnutrition, but specific aspects of RH, as expressed in the MISP, also must be addressed. Rather than trying to implement a broad range of RH activities, limiting the scope of RH in the emergency phase to the MISP ensures focused attention on essential actions in emergencies where human and material resources are scarce.

What are the possible consequences of ignoring the MISP in an emergency setting?

The lives of the displaced, particularly women and girls, are put at risk when the MISP is not implemented. For example, women and girls can be placed at risk of sexual violence when attempting to access food, firewood, water and latrines. Their shelter may not be adequate to protect them from intruders or they may be placed in a housing situation that deprives them of their privacy. Those in power may exploit vulnerable women and girls by withholding access to essential goods in exchange for sex. Not observing universal precautions in a health care setting may allow the transmission of HIV to patients or health workers. Without a referral system in place to transfer patients in need of emergency obstetric care services (e.g., cesarean section) to an equipped health facility, women may die or suffer long-term injuries (e.g., obstetric fistula). The MISP provides an outline of the basic steps to be taken in order avoid these negative consequences.

Who is responsible for implementing the MISP?

Humanitarian workers are responsible for ensuring that MISP priority activities are implemented. MISP activities are not limited to reproductive health staff or even the general health sector. The MISP cuts across all sectors in addition to health, including food security, water and sanitation services and shelter.

Is this the stable phase or not? It is often unclear when the crisis or emergency phase is over and the stable phase begins. The UN High Commissioner for Refugees' working definition of an emergency is any situation in which the life or well-being of the refugees will be threatened unless immediate and appropriate action is taken, and which demands an extraordinary response and exceptional measures. The World Health Organization (WHO) and the Centers for Disease Control and Prevention define the emergency phase as the period where the crude mortality rate is above one death per 10,000 per day. This phase is often characterized by internal or cross-border population displacement, a change in authority at local or national levels, a breakdown in infrastructure (such as health and legal institutions), impaired access to food and increased mortality rates. The post-crisis phase begins when mortality rates return to the level of the surrounding population and basic needs are met. Confidence in security rises, health services are normalized, long-term approaches can be introduced and capacity building and reconstruction can be initiated. The emergency phase may last only a few months, although the post-emergency phase can deteriorate to an acute phase again if the conflict resumes. Chronic emergency settings are often characterized by political deadlock and certain areas may stay in an acute phase while others move towards the post-emergency phase. 8

How can an agency obtain funding to support MISP activities?

Nongovernmental organizations (NGOs) responding to a humanitarian crisis should include funding for MISP activities in proposals to donors such as the Office of Foreign Disaster Assistance (OFDA), United States Bureau for Population, Refugees and Migration (BPRM), the United Nations High Commissioner for Refugees (UNHCR), United Nations Population Fund (UNFPA), Humanitarian Aid Office of the European Commission (ECHO) or private donors who may support emergency response activities. It is important that the proposals describe the priority RH activities as outlined in the MISP as the first RH components to be addressed, followed by an expansion of RH programming once the MISP has been fully implemented. It also may be helpful to cite the Sphere standards in proposals. In the 2004 edition of the Sphere Handbook, the MISP is listed under Control of non-communicable diseases (standard 2, reproductive health, p. 288) within the health services section. See Annex B in this module on sample funding proposals for examples of narratives and budgets for submission to government, United Nations and other donors.

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