Chapter 2
Coordination of the MISP

A qualified and experienced person should be identified to coordinate RH activities at the start of the emergency response. The overall leading agency should be responsible for designating this RH Coordinator (also known as RH Focal Point or MISP Coordinator/Focal Point) and this person should be supervised by the overall Health Coordinator. Ideally, there should not only be an overall RH Coordinator for each displaced setting but each agency should also have an RH Coordinator on its response team or a designated health person responsible for the MISP. Emergency RH professionals should be in their post for a minimum of six months, as it typically takes at least this amount of time to implement the MISP and make the transition to providing comprehensive RH services.

The following is a broad terms of reference to be undertaken by an overall RH Coordinator. (See the MISP Fact Sheet in Appendix D for a user-friendly summary and check list to assist an RH Coordinator in her/his work.)

OBJECTIVE TO IDENTIFY AN ORGANIZATION(S) AND INDIVIDUAL(S) TO FACILITATE THE COORDINATION AND IMPLEMENTATION OF THE MISP.   The RH Coordinator should: be the focal point for RH services and provide technical advice and assistance on RH to the displaced communities and all organizations working in health and other sectors as needed; liaise with national and regional authorities when planning and implementing RH activities in camps, settlements and among the surrounding population; liaise with other sectors (protection, community services, camp management, education, etc.) to ensure a multi-sectoral approach to RH; assure that RH is a standard item on the health coordination meeting agenda; create or adapt and introduce national and other standardized policies that support the MISP and ensure that they are integrated with primary health care, for example, policies relating to emergency obstetric care or gender-based violence; initiate and coordinate audience-specific orientation sessions on the MISP (e.g., for health workers, community services officers, the beneficiary population, security personnel, etc.); introduce standardized protocols for selected areas (such as medical response to survivors of sexual violence and referral of obstetric emergencies; and, when planning for comprehensive RH services: syndromic case management of STIs and family planning); adapt and introduce simple forms for monitoring RH activities during the emergency phase that can become more comprehensive once the program is expanded (see monitoring and evaluation in Appendix A of this module); use standard indicators to monitor MISP outcomes; collect, analyze and disseminate data for use; report regularly to the health coordination team.

Good practices in facilitating the coordination and implementation of the MISP observed in Darfur [9] In West Darfur, the sub-grantee established a good relationship with the Ministry of Health (MOH), which they noted was crucial to implementing all the components of the MISP. Successful advocacy was achieved by UNFPA with the MOH in South Darfur to allow emergency obstetric care (EmOC) at the peripheral levels (in camps and villages). Different agencies noted that working with a national counterpart is also important to promote sustainability. UNFPA is successfully working with the Advisory Council on Human Rights to train judges, doctors, lawyers, police and others on Form 8--a form that was previously mandatory for women who had experienced sexual violence before they could receive medical care.

Why is putting in place an RH Coordinator a priority?

Without an individual or agency leading RH activities in emergency settings, evidence has shown that RH is typically overridden by the other emergency concerns such as ensuring that the population has access to sufficient food, water and shelter. An RH Coordinator has the ability to make RH a priority and facilitate implementation of the MISP.

The diagram, which you can access here, provides an example of the various levels of coordination at the site/camp, agency, sub-regional, country and international levels in three separate settings. It should be kept in mind that this is an ideal scenario and, in reality, the situation may not be as organized. However, the point of the example is to demonstrate coordination at all levels.

Site Level

At the site level, the diagram shows a variety of configurations to demonstrate the different ways in which humanitarian agencies may be organized to serve the needs of the displaced population housed in such setting.

Site A has two humanitarian agencies providing the services in the site which include health, protection/legal, community services and site management. (For this example, services have been divided into these four main areas, but this may vary depending upon setting.) Site B has three agencies providing these same services, while in Site C all of the services are provided by one agency.

Here are a few examples of how coordination activities may occur:

	Site A: Agency #1, which manages the protection/legal sector, receives a report of a rape incident and refers the survivor immediately to health services, provided by Agency #2. Having this case addressed and coordinated among both agencies allows the survivor to access clinical services and also seek legal recourse if she chooses to do so.
	Site B: Agency #2, which is responsible for community services, collaborates with Agency #1, the health services provider, to obtain condoms. The community service manager places the condoms in appropriate venues such as offices and community meeting spaces and distributes them to her staff to ensure that condoms are free and visible to the displaced population and agency staff alike. The community services manager also requests Agency #3, the site manager, to place condoms in other appropriate areas where staff and the displaced assemble. Coordination in this setting may be a more challenging endeavor because of the number of agencies involved in providing services to the displaced population in this site.
	Site C: Agency #4, although it is the lone service provider in the camp and therefore coordination with other agencies is not an issue, should be aware of the good practices and developments that have occurred in the other sites. For example, the agencies working in Sites A and B recently performed a health facility assessment of the two local referral hospitals. They found that one facility was so badly damaged in the local conflict that they decided to abandon this facility and focus on fully equipping and staffing the other facility which was also closer to the sites. This is important information for Agency #4 to know so that it refers patients to the most appropriate health facility.

Despite the different configurations in these examples of site settings, each agency is responsible for coordinating MISP activities.

Sub-regional Level:

It is important for all agencies responding to emergencies to participate in the coordination activities occurring among sites, whether this is weekly, bi-weekly or monthly meetings. The role of the RH Coordinator at this level is to work with the host government MOH where possible to provide RH technical assistance to these agencies; ensure that coordination is happening among the various sectors to ensure a multi-sectoral implementation of MISP activities; and provide specific orientation sessions on the MISP for the agency staff, which may include health workers, community services officers, security officers, the displaced, etc. In addition, the RH Coordinator can ensure that standardized protocols are being used by the agencies to facilitate MISP implementation.

Example:
The RH Coordinator can ensure that each agency is using WHO/UNHCR’s Clinical Management of Rape Survivors [10] or other standard protocols for medical management of rape survivors (e.g., protocol from Médecins Sans Frontières or MOH) and that staff are trained on the protocol. Site health surveillance forms should also be adapted to document the number of survivors of sexual violence treated and maternal and neonatal deaths. The RH Coordinator also can introduce simple forms for monitoring MISP activities (or adapt ones already familiar to agency staff). These forms can include more information once the situation moves to a stable phase and comprehensive RH services are being established. Although maternal and neonatal deaths are relatively rare, unless they are documented, maternal and neonatal mortality may not be addressed. In addition, the RH Coordinator is responsible for collecting information from each site setting and compiling it in a report that can be shared at the country level with UN and government agencies.

Country Level:

As the diagram shows, an RH Coordinator should also be appointed at the country level to collect information from all the sub-regions. This person has the full picture of RH issues for the displaced population in the country.

Example:
In response to the tsunami crisis, UNFPA fielded RH Coordinators in Indonesia and Sri Lanka. The RH Coordinators initiated coordination meetings in each country at the start of the crisis which spurred more agencies than were initially interested in RH to participate and share information about their RH service provision activities. This coordination also provided the entry point to monitor the supply needs of agencies as well as to facilitate data collection.

International Level:

On the international level, the IAWG is a mechanism where collaboration occurs among UN and government agencies, donors and NGOs. The group provides a forum in which local and international partners share activities and resources, initiate collaborative efforts and analyze issues in the field to be addressed. For more details on joining IAWG, please email info@rhrc.org.

Example:
From 2002 to 2004, the IAWG undertook the global evaluation, Reproductive Health Services for Refugees and Internally Displaced Persons,[11] which assessed how the reproductive health field had progressed in the past decade. This led to the formation of six working groups to tackle the most pressing topics, one of which was the lack of proper implementation of the MISP. Since the formation of the working groups in December 2004, the MISP working group has been meeting by teleconference to share findings from the crisis response on the tsunami in Indonesia, Sri Lanka, the Maldives and other affected regions. These activities have informed response activities and helped to support a more coordinated and effective response to tsunami-stricken areas. This is an example of how action at the global level can support activities in the field.

The Reality of Implementing the MISP in Thailand From the end of September to mid-November 1997, a steady stream of Cambodian refugees poured across the border into Thailand. The American Refugee Committee (ARC) was the only NGO on the scene to offer emergency relief and primary health care, including RH services, to some 40,000 refugees in two camps. It was one of the few occasions since the RHRC Consortium began its work that the MISP was deployed at the height of a refugee influx. Sterile medical supplies were readily available, both from ARC's own stocks and from the refugee community itself. ARC supplied gloves, obtained condoms and held training sessions on universal precautions [12] for HIV/AIDS prevention for health workers in both camps. Refugee women with emergency obstetric complications benefited from an established camp referral system that provided transportation to a provincial hospital, where a full range of obstetric services was available to the refugees. Though camp midwives denied knowledge of any incidents of gender-based violence in flight or in the camps, ARC offered the midwives training sessions on emergency post-coital contraceptives and on identifying and treating women who are victims of sexual violence. "In the first days, the refugees went through a shock phase. Their priorities were shelter, food and water," said the international health advisor at ARC who coordinated the MISP along the Thai-Cambodian border. "But day by day, more health workers came forward to work in the community and in the clinics. They were motivated and eager to learn." Rapid responses in similar crisis situations would be more assured if field offices of international agencies, such as UNICEF, UNHCR and UNFPA, stocked MISP supplies or knew how to obtain them quickly. "We were fortunate in Thailand," the ARC advisor said, "because you can buy medical supplies in most large towns and assemble essential materials and basic kits, and that's what we did. But UN organizations should stock emergency supplies regionally. You need them on the first day." Essential to the success of MISP is the presence of a focal person, experienced in emergency settings, to oversee the program. "You need someone who can set up the MISP in the environment of a potential cholera or measles epidemic," said the international health advisor, "someone who can see how the MISP fits into the situation, but doesn't compromise the response to other emergency needs; who sees what can be done and does it." [13]

MISP Coordination Monitoring

It is the RH Coordinator's role to monitor and evaluate the MISP activities. She/he should collect or estimate basic demographic and health information of the affected population. (See Chapter 9 of the Reproductive Health in Refugee Situations: An Inter-agency Field Manual.) [14] Total population Number of women of reproductive age (ages 15 to 49, estimated at 25 percent of population) Number of sexually active men (estimated at 20 percent of population) Crude birth rate (estimated at 4 percent of the population) Age-specific mortality rate (including neonatal deaths 0 to 28 days) Sex-specific mortality rate To monitor and evaluate the implementation of the MISP, the following data should be collected every month as a minimum (see Appendix A on monitoring and evaluation): Number of condoms distributed Number of clean delivery packages distributed Number of sexual violence cases reported in all sectors (confidential and anonymous reporting is essential) Number of health facilities with adequate supplies for universal precautions Indicators to monitor overall coordination Overall RH Coordinator in place and functioning under the health coordination team RH focal points in camps and implementing agencies in place Material for implementation of the MISP available and used Which supplies are required for coordinating the implementation of the MISP? [15] Number Name Color Kit 0: Administration sub-kit Orange

Challenges and Solutions

1. Sometimes a lack of understanding and/or prioritization of RH by humanitarian actors can make coordination difficult. How can one counteract such apathy and dismissal of RH issues?   In the short term, one could point to the fact that the MISP is a Sphere standard and is thus an internationally recognized, universal minimum standard in disaster response to which each humanitarian agency is obligated to adhere. One could emphasize that it is a lifesaving intervention. From a longer-term perspective, agencies should be encouraged-based on the Sphere standard-to prioritize RH in their emergency preparedness planning. One could also encourage staff to complete the MISP module as well as use the module to educate and advocate to relevant agency staff and others about the importance of implementing the MISP. 2. At the beginning of an emergency, UNFPA and other specialist agencies may not yet be operational in the field. Security may be poor and capacity of staff may be very weak. In such a setting, the reality of trying to adequately implement all elements of the MISP can be very challenging. In what ways can an individual, small group or agency address this problem?   If your agency is assuming responsibility in the health sector, it should ensure the MISP is included in its response. Your agency or another agency could volunteer to establish regular meetings to coordinate implementation of the MISP. Contacting UNFPA in Geneva or New York could also help to identify in-country support.   The next three chapters focus on the technical areas of the MISP, including preventing and responding to sexual violence, reducing HIV transmission and preventing excess maternal and neonatal mortality and morbidity.

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NOTES

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