Minimum Initial Services Package (MISP)

Key Messages

• The Minimum Initial Service Package (MISP) for Reproductive Health (RH) is a set of priority activities to be implemented during the early stages of an emergency (conflict or natural disaster).
• The MISP is designed to: prevent and respond to sexual violence; prevent excess neonatal and maternal morbidity and mortality; reduce HIV transmission; and plan for comprehensive RH services.
• When implemented at the onset of a crisis, the MISP saves lives and prevents illness, especially among women and girls.
• The MISP is a standard in the 2004 revision of the Sphere Humanitarian Charter and Minimum Standards in Disaster Response for humanitarian assistance providers.
• The MISP can be implemented without a new needs assessment because documented evidence already justifies its use.
• Neglecting RH in emergencies has serious consequences: preventable maternal and infant deaths; unwanted pregnancies and subsequent unsafe abortions; and the spread of sexually transmitted infections, including HIV/AIDS.
• While all humanitarian workers are responsible for implementation of the MISP, it is essential to immediately designate a RH Coordinator/Focal Point who is experienced in emergency settings and is able to coordinate and facilitate RH activities at the beginning of every new emergency.
• Gender-based violence (GBV) is strongly associated with situations of forced population movement.[1] The MISP can help to 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 and ensuring medical services, including psychosocial support, are available for survivors of sexual violence.
• Fifteen percent of all pregnant women will experience an unpredictable obstetric complication. Without access to emergency obstetric services, many women will die or suffer long-term health consequences that are preventable.
• HIV can spread quickly where there is poverty, powerlessness and instability. The MISP helps to prevent the transmission of HIV by emphasizing the importance of universal precautions (a set of safety measures to prevent HIV transmission), making free condoms readily available and ensuring blood for transfusion is safe. Introducing reproductive and sexual health services during the initial phase of a crisis can substantially contribute to reducing HIV transmission.[2]
• Once humanitarian actors are familiar with the priority activities of the MISP they will recognize that it can be provided within the context of other critical priorities such as food, water and shelter.

 Overview

The MISP is a set of priority activities responding to RH needs of populations at the onset of an emergency.  The MISP is designed to: prevent and respond to sexual violence; prevent excess maternal and neonatal mortality and morbidity; reduce HIV transmission; and plan for comprehensive RH services. It includes a kit of equipment and supplies to complement the set of priority activities that must be implemented in the early days and weeks of a crisis in a coordinated manner by trained staff. The MISP can be implemented without a new needs assessment because documented evidence already justifies its use. The components of the MISP form a minimum requirement and it is expected that comprehensive RH services will be provided as soon as all components have been implemented. Humanitarian workers are responsible for ensuring that MISP priority activities are implemented. However, MISP activities are not limited to RH 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. The MISP is a standard in the 2004 revised version of the Sphere Humanitarian Charter and Minimum Standards in Disaster Response for humanitarian assistance providers.

Facts

Global Statistics

• Newborn and maternal deaths rates are highest in the poorest, most disadvantaged places.  99 percent of neonatal and 98 percent of maternal deaths occur in developing countries where women and newborns do not have access to basic health care services.[3]
• Pregnancy, childbirth, and their consequences are still the leading cause of death, disease and disability among women of reproductive age in developing countries—more than any other single health problem.[4]
• Every year, some eight million women suffer pregnancy-related complications and over half a million die.  More than 80 percent of maternal deaths could be avoided with actions that are effective and affordable, even in developing countries. [5]
• Each year, approximately 3.3 million babies are stillborn, another 4 million die within the first month of their lives and 6.6 million young children die before they reach their fifth birthday.[6]
• An estimated 4.9 million people were newly infected with HIV in 2005.[7] More than 25 million people have died of AIDS since the beginning of the epidemic and an estimated 3.1 million deaths occurred in 2005.[8]

Refugee/Internally Displaced/Conflict-affected Statistics

• A MISP assessment in tsunami-affected areas of Indonesia in February 2005 found that only 52% of humanitarian workers interviewed had actually heard of the MISP, and only one of 25 people could accurately describe its overall goal, objectives and priority activities.[9]
• Newborn mortality rates are especially high in post-conflict countries or those with on-going civil unrest, such as Afghanistan, Angola, Iraq, Liberia and Sierra Leone. These are also places where mothers are at high risk of death during pregnancy and childbirth.[10]
• A 2004 MISP assessment of Sudanese refugees in Chad revealed that most humanitarian actors were not familiar with the MISP and subsequently did not know the MISP’s overall goal, key objectives and priority activities. There was no overall RH focal point and only one agency with an identified RH focal point.[11]
• A 2003 assessment of RH care services among Afghan refugees in Pakistan found that only six of the 18 refugee camps surveyed had a RH focal point.[12]
• Although women and girls represent 55 percent of the 2 million people displaced in Colombia, an assessment in 2003 found that RH focal points were non-existent and agencies were not planning to implement the MISP.[13]
• During the conflict in the Balkans in the early 1990s, 20,000 to 50,000 women were raped in Bosnia and Herzegovina.[14]
• An estimated 250,000 to 500,000 Tutsi women were raped during Rwanda's 1994 genocide.[15]
• Approximately 20 percent of women of reproductive age in any refugee population will be pregnant at one time. As with all women, 15 percent of them will suffer from unforeseen complications of pregnancy and childbirth.[16]

Case Studies

Emergency response includes the MISP and the community

Naw Ruth Say, a 30-year-old midwife, fled her native Burma (Myanmar) in 1997, leaving behind her family. She was one of some 5,000 ethnic minority group members forced by Burmese Army advances to cross the border into Thailand. Committed to her role in the community, Naw Ruth Say was determined to assist refugee women during their flight. The refugees spent three weeks scattered along the roadside in Thailand before Nu Poh camp was established. A RH coordinator working with the international nongovernmental organization American Refugee Committee (ARC) identified Naw Ruth Say, who identified other midwives and traditional birth attendants (TBAs) within the displaced community. During informal meetings in shelters along the roadside, midwives and TBAs were informed about the importance of assisting survivors of rape, taking into account the wishes of the survivor. Naw Ruth Say reported hearing about incidents of rape that had occurred during flight and said that the Burmese Army had reportedly abducted several women. No rape survivors had yet been identified and assisted. Clean delivery supplies (plastic sheeting, gloves, two cloth strings, a bar of soap and a razor blade) and midwife supplies were purchased in the nearest town, assembled into kits and distributed to TBAs and midwives. ARC organized meetings with midwives, TBAs, community outreach workers and community leaders to discuss the issue of women's security and to develop an emergency referral system to ensure that women suffering from delivery complications were transferred to Umphang District hospital without delay. Condoms were purchased in Thailand and made visibly available on tables in three makeshift clinics. Due to MISP activities during this critical emergency phase, pregnant women had access to clean deliveries and emergency obstetric care, preventing maternal and infant illness and death; health workers practiced universal precautions, for example, wearing latex gloves and appropriately disposing of needles and other sharps; and condoms were available to prevent the spread of sexually transmitted infections, including HIV/AIDS.

Implementing the MISP for Cambodian refugees in Thailand

From the end of September to mid-November 1997, a steady stream of Cambodian refugees poured across the border into Thailand. The ARC was the only NGO on the scene to offer emergency relief and primary health care, including RH services, to some 40,000 refugees. 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 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,” she 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.”

Case Studies from Darfuri Refugees in Chad

The following case studies are from a recent MISP assessment in Chad conducted by UNFPA and the Women’s Commission for Refugee Women and Children in April 2004.

Gender-based violence in Adré

A group of men from the Masalit ethnic group living in the town of Adré on the Chad border tried to estimate how many women in their community had been raped. They stated that of the 80 families in their area everyone had at least one woman—a mother, a sister, a daughter—who had survived rape. They also described how in October 2003, the Janjaweed attacked their villages and abducted young girls and women and would rape them over a three to four day period and then return them to the village. If the villagers refused to go or let the women go, they were killed. The Janjaweed continued to attack the villages and most of the people in this area fled in November 2003—women continued to be raped during this period and during their flight to Chad. Incidents of sexual violence were not reported in Chad, however, a woman collecting reeds for building a shelter was beaten by the Janjaweed. Women collected water and firewood from the wadi, a dry riverbed near the Sudan border, but never crossed the border for fear of being attacked by the Janjaweed. There were no extra protection measures in place in the camp to protect women from sexual violence; however, the main cause for concern was the overall lack of security from attacks by the Janjaweed. There were many women in the camp without their husbands because so many men had been killed by the Janjaweed.

HIV/AIDS in Iridimi Camp

Iridimi camp is located near the northern Chadian border. Iridimi started as a transit center for refugees but with a population of over 5,000 refugees, it was being reconfigured as a permanent site during the assessment team’s visit. Adolescent boys participating in a focus group reported (while laughing) that when someone dies of AIDS, their body must be burned because it could infect others in the village. They said that they are worried about getting HIV/AIDS. To prevent HIV, they suggested not eating with someone who has HIV, don’t take the infected person’s blood, do not drink the water or be near an infected person, do not use their blanket. They do not know what a condom is and don’t know if people in this setting would use condoms. Sex education consists of teachers advising them not to have sex.

Same motherhood in Tine

In the border town of Tine, Chad the assessment team also met a 36-year-old refugee woman, Kadija, from Karnoi, Sudan, who had fled attacks from the Janjaweed and the Sudanese military when she was nine months pregnant. Three days into her journey she gave birth under trees on the side of the road without any supplies to make her delivery safe—no soap, clean razor, cord or plastic sheet to keep her and her newborn clean. Luckily, Kadija had no complications and her eighth baby was born healthy. Afraid to be caught by the Janjaweed and the Sudanese military, she continued to walk—for eight more days. During the flight, her 14-year-old son was injured in a bombing. Kadija is less worried about her son's physical injuries than about the long-term psychological effects of the attack. At night she has to tie his arms or give him medicines to make sure he doesn't hurt himself and is able to sleep. He never had these problems before the crisis, Kadija says.

Resources

Click here for more resources on the MISP for Reproductive Health.

Updated September 2006