July 2007, eastern Democratic Republic of Congo (DRC): A woman has been in labour for three days. The child is obstructed; the mother, in unbearable pain, has been trying to reach the main district hospital for the last 48 hours – on foot at first, and then by boat, the engine of which has broken down in the middle of the lake. The woman and other passengers are stuck, floating aimlessly. There are no toilets, no food and no fresh drinking water on board.
By sheer coincidence, a team of NGO medical staff, including a midwife, are on a motorboat going to one of the health clinics accessible only by water. The passengers on the drifting boat flag down the motorboat, and the woman in labour is brought on board. The NGO midwife assesses the situation and immediately decides to head to the district hospital. The baby has long since died. The woman is alive, however, and a team in town is radioed to prepare a car at the port. One hour later the motorboat arrives at the port. The woman in labour gets into the car and in hospital a mere 10 minutes later. The hospital is the reference hospital for a large area; it has been supported by an international NGO for years, and is run by the Ministry of Health. Although the hospital is understaffed and has faulty electricity supplies at best, doctors are standing by to help the labouring woman – but there are no sterile surgical supplies, no anaesthetic or antibiotics, no IV bags or tubing. The woman died.
The hospital was accessible, doctors were available – so what went wrong?
The logistics of crisis
By their very nature, humanitarian crises render vital services and supplies inaccessible. In conflict areas, lack of security may be only the first of several major obstacles. For example, as the supply chain lengthens to circumvent dangerous areas, the cost of supplies and services increases. For these reasons, planning and coordinating the logistics of programme response are crucial. Indeed, through such efforts as pre-positioning, strategic location of warehouses, chartering planes and improving on-the-ground collaboration, the humanitarian community has made progress in addressing logistics planning for needs such as food, water, shelter and some medical care.
Yet despite these efforts, comprehensive reproductive health (RH) services and supplies are not generally prioritised at the level of other key emergency medical interventions. Comprehensive RH care encompasses emergency obstetric care, including the provision of family planning methods; responses to gender-based violence; services to mitigate the effects of unsafe abortion; and the prevention and treatment of sexually transmitted infections, including HIV/AIDS. Every year, for lack of emergency obstetric care alone, more than 500,000 women die – including some 170,000 in situations of humanitarian emergency – and many more are permanently disabled. Lack of comprehensive RH care is also a major cause of neonatal deaths.
The ‘Three Delays’ model provides a framework explaining why women die in pregnancy. The first delay is the time that the family or the community takes to recognise the need to seek medical intervention; the second is the delay experienced getting to the health facility; and the third delay occurs in getting appropriate care at the facility itself. In the case described at the beginning of this article, the patient was delayed in seeking care and in reaching the facility. Once she arrived at the hospital, skilled providers were available; yet without essential supplies and equipment they were unable to save her life.
Some humanitarian actors do have processes in place to facilitate the availability of key RH supplies. For example, the United Nations Populations Fund (UNFPA) has developed an RH kit for emergencies, targeted for use in the initial phase of the emergency. But UNFPA must sometimes depend on other agencies to deliver these RH emergency kits, as transfers in-country may be lengthy, complex and/or prohibitively expensive. Without commitment from other humanitarian actors, RH supply and service provision often remains minimal or effectively unavailable.
Other key logistics players in humanitarian settings may not view RH supplies and services as priority interventions in humanitarian crises. For example, recipient governments may not include life-saving RH supplies in their logistics planning efforts. Some cheap and effective drugs for the management of RH conditions are not currently registered for these uses on the World Health Organization (WHO) Essential Drugs List or not included by governments in their own essential drugs lists. And governments sometimes obstruct customs clearance for vital RH supplies or otherwise delay humanitarian response.
Making the right RH supplies accessible at the onset of an emergency is paramount if humanitarian actors are serious about saving lives and treating the beneficiaries with the dignity they deserve. The challenges of getting RH supplies to emergency settings are great, and solutions must be devised at field, headquarters and government levels, including the need to:
• raise awareness within the humanitarian community: first and foremost, humanitarian actors must acknowledge RH care as a primary need alongside food, shelter, sanitation and other key components of primary health care.
• broaden governmental and WHO support: RH organisations must work with WHO and governments to ensure that appropriate medication and RH supplies are included on essential drug lists.
• coordinate with logistics actors: RH organisations must collaborate with other major humanitarian actors, especially those involved in first response and logistics efforts such as pre-positioning supplies. They must ensure that RH commodities become a standard item on early flights out to any emergency.
• engage with donors: humanitarian actors must work closely with major donors to emphasise the need for shifting from the Minimum Initial Service Package (MISP) for RH in crisis situations towards comprehensive RH care as quickly as possible. Although some key donors do understand the importance of logistics, many have yet to recognise the vital role of RH products and therefore fail to include them in the pre-positioning of humanitarian goods.
• expand current efforts to provide RH care: humanitarian actors who are currently making occasional or partial efforts to incorporate RH supplies into emergency response must be encouraged to prioritise these services and supplies.
The provision of comprehensive RH services in all situations would make it possible to prevent many unnecessary deaths. Humanitarian actors must work to ensure that this universal human right is approached with the same level of urgency and foresight as are other aspects of humanitarian crisis.
Maaike van Min (Maaike.email@example.com) is an Advocacy Manager for the RAISE Initiative in the Marie Stopes International Brussels office.
 see FMR 18 ‘Delivering the goods: rethinking humanitarian logistics’, September 2003