Reproductive health care (RHC) has potential benefits for individuals, families, communities and nations, and there is no doubt that such care can be effective. Peter Poore suggests, however, that the real issue in reproductive health care for refugees is how to reconcile the disparity between the services that should be offered and those that are available, given the practical, logistical, cultural and social constraints which may be operating in any particular refugee situation.
The 'right to health' of refugees is acknowledged in UN documents1. Securing these rights in practice, however, often falls short of the promise. Reproductive health is dependent upon more than just the provision of care.
Denial of the social, political and economic rights of women around the world perpetuates the discrepancies in health status and educational opportunity between the sexes at all ages and favours the continuing exploitation of girls and women, socially, economically and sexually. Addressing these issues is at the heart of securing the right to health.
Reproductive health care has potential benefits not only for individuals but also for families, communities and nations. It can raise the health status of women, improve the outcome of pregnancy, lower the burden of death and disease amongst women and therefore their children, and increase the range of choices available to couples who wish to plan their families. Good care can offer some protection against sexual violence, including rape and genital mutilation, and lessen the risks of unsafe abortion.
Maternal care is an essential part of RHC. Maternal mortality rates in the countries where most refugees come from, and go to, are 200 times higher than in industrialised countries. This is unsurprising because so much of the mortality is attributable to causes which require access to skills and services which can either surgically interrupt labour, or manage severe haemorrhage, anaemia, infection, hypertensive disease, and the harmful effects of unsafe abortion. These services are expensive and rarely exist where and when they are needed in poor countries.
There is little dispute about what reproductive health care should be offered to refugees, and no doubt that such care can be effective if delivered to the right person at the right time by sufficiently well-trained and supported staff. However, the 'menu' of services and interventions which should ideally be delivered must be reconciled with what it is possible to deliver at any one time, in any one refugee situation.
In poor environments there will always be a need to compromise between the quality and the quantity of care available; but if either the quality or the accessibility of the service is inadequate to address the need, then the service will be of no value. The provision of reproductive health services is clearly a priority. It is not, however, a question of what should be done, but more one of what can be done in a particular situation, and every situation will be different.
A number of key factors will determine the needs, including the reproductive health needs, of refugees and the opportunities which service providers will have to fulfil them.
This will vary enormously and depend to some extent on the causes of flight. At one extreme, the one million people who fled Rwanda in the space of a few days during the recent civil conflict were enough to almost overwhelm the capacity of any agency to respond effectively to their immediate needs.
The provision of services will depend upon how people organise themselves within any community, and how secure that community is. A knowledge of how the community 'works' who makes the decisions and who controls events is essential if any intervention is to be useful. The imposition of any action on an unwilling or uncooperative community will certainly fail.
Refugees may comprise whole families, predominantly women and children (eg the camps in Luwero during the Ugandan civil war where most of the men were combatants) or, less commonly, may be mostly men, children, or the elderly.
their homes, how far they moved, what state they were in when they left, and what state they were in when they arrived. It will also depend upon what services were available in their homes, during their flight, and in the host country; whether or not they are acknowledged as refugees by the host country; and how they were treated on the way and on arrival. The author reports that many of the Kurdish refugees from Northern Iraq who fled from Saddam Hussein, left prosperous homes where there were good health facilities. They drove to the border in their own cars but then had to walk over snow-covered mountains, where many died. In Turkey, they were held just below the snow line where it was extremely difficult to provide basic services. The high mortality rate was a result of a political decision rather than a lack of resources. By contrast, those Kurds who went to the Iranian border were received as refugees and dealt with efficiently by the Iranian authorities. Mortality rates were reportedly lower in Iran.
to provide or coordinate resources such as people, money, equipment and consumables will determine its capacity to respond to the needs of the refugees. The absolute amount of money that is available for the emergency relief of refugees has increased but, by contrast, the resources available for the development of health services in those countries which are both home and host to refugees have declined. As a result, host countries are increasingly unable to provide adequate services for refugees. Furthermore, some countries are unwilling to accept responsibility and are even actively hostile to refugees.
varies considerably, and perhaps more than anything else determines the effectiveness of response. The number of agencies responding to emergencies has increased considerably in recent years. The problems of coordination, accountability, competence and organisation have increased as a result of this, as yet, unmanaged interest.
may determine which services can be delivered. A well-established refugee camp, adequately resourced, will often be able to offer most, if not all, of the basic necessities. In these circumstances, health indicators such as Infant Mortality Rate (IMR) and Maternal Mortality Rates (MMR) can be reduced. Indeed there are many examples where the welfare of refugees in camps is better than that of the indigenous population. Maternal mortality has been virtually eliminated from the Bhutanese refugees in camps in eastern Nepal, although the MMR in Bhutan2 is amongst the worst in the world and is also very high amongst the indigenous Nepali women.
International response to disasters is heavily influenced by news reports. Reporting of disasters is, however, incomplete; it always seeks the dramatic and loses interest rapidly. As a result, there are many 'hidden emergencies' which go unreported and are uncared for.
What can be done to improve the provision of reproductive health care amongst refugees?
1. Be prepared. A great deal is already known about the health risks to refugees in any circumstances. The immediate need for the basics is invariable adequate safe water, appropriate sanitation, shelter, food and preventive and curative care. Awareness and utilisation of this 'background' information as well as early and rapid appraisal of the site and the situation with the full cooperation of the community and their leaders, is essential to plan an effective response.
2. Promote an international code of conduct which can be used by all agencies working in emergencies to ensure coordination, accountability and the optimal use of resources. This will avoid the common situation today where agencies compete with one another for resources on offer from donors, without the need for accountability for the quality of service provided. This applies equally to UN agencies and NGOs.
3. Standardise the approach to the prevention, management and treatment of common conditions in reproductive health. This is relatively uncontentious. We know what to do about most conditions, and the medicines and equipment to provide interventions exist. The draft field manual which is being prepared by the United Nations High Commissioner for Refugees and the United Nations Population Fund should provide guidelines on procedure to each level of health staff in the field. Both technical and managerial guidelines will improve the quality of care and the optimal use of limited resources. A standard, common approach will also facilitate the training of health staff at all levels.
4. Acknowledge that specific reproductive health needs may present as a priority. Understand the special needs of women and girls. Clearly, in most circumstances, women will continue to have babies. Their obstetric and perinatal needs must be acknowledged and emergency care provided for in the best way possible. Most births will take place in the home and this is where any service must focus its attention if it is to establish an effective contact and referral service.
5. Protect women from sexual violence. Sexual violence is commonplace in times of conflict and social disruption. It is an acknowledged fact that rape is used as a weapon of war. Protection of women must be a major consideration when establishing services which require women to leave their homes or stay overnight in health centres. Emergency contraception following rape could prevent many pregnancies, but the circumstances in which rape may occur as a weapon of war would often preclude the availability of such a contraceptive service within a time period when it would be effective.
6. Prepare for the mitigation of disasters. A number of techniques have been developed which can 'map' inherent and potential risks, and which can analyse and interpret vulnerability3.
7. Invest in the capacity of host governments, where this applies, to coordinate responses from foreign and indigenous agencies. Review the distinction made by donors between 'emergencies' and 'development'. This often only has relevance in that donors impose the distinction for the purpose of fundraising and budgeting. It seldom has any other validity, and often means that opportunities to contribute to longer term rehabilitation and the process of development are missed. An example of this is that whilst health needs are classified as 'emergencies', educational services are considered to be 'development' and often cannot be funded from emergency budgets.
8. Invest in the social services of the poorer countries of the world so that they are better able to provide for their own people as well as for the internally displaced and refugees from other countries.
9. Reaffirm the right to health for all. Equity and the right to health, including reproductive health, is under threat. The need for cost effectiveness must not be used to deny the right to health to those, such as refugees and internally displaced peoples, who are expensive to reach.
The failure of governments, UN agencies and NGOs to address adequately the reproductive health needs of refugees is not technical, but organisational. Our response all too often is too late, too little, insensitive, inflexible, inappropriate, uncoordinated, unaccountable and of varying quality. The provision of services to people who, for whatever reason, have been displaced from their homes will always depend upon setting priorities according to circumstance, need and opportunity. The ability to draw such conclusions rapidly is fundamental to good practice and effective response as is consultation with, and participation of, the refugee community. The uncoordinated, inappropriate imposition of any 'service' on an uninformed, unwilling and uncooperative community will always fail.
These are the issues which must be addressed and resolved. If they are not, the rights of refugees to reproductive health care will continue to be denied.
Peter Poore is Senior Health Adviser for Save the Children Fund UK.
1. Article 13, UN Charter. Article 25, UN declaration on human rights 1948. Article 12, International covenant on economic social and cultural rights 1967. Article 24, Convention on the rights of the child 1989.
2. Parajuli J, Pregnancy: an event of happiness or a matter of concern, SCF Jhapa, Nepal, March 1995.
3. Seaman, Holt and Allen, A new approach to vulnerability mapping for areas at risk of food crisis, SCF, May 1993.
October 1996