“Chapter Two: Minimum Initial Services Package (MISP)” in Reproductive Health in Refugee Situations: An Inter-agency Field Manual (1999), by the Inter-Agency Working Group on Reproductive Health in Crises

In 1999, the Inter-agency Working Group on Reproductive Health in Crises, hereafter the IAWG, published the Minimum Initial Services Package, hereafter MISP, which is the second chapter in Reproductive Health in Refugee Situations: An Inter-agency Field Manual. The IAWG wrote MISP for governments and agencies who respond to humanitarian crises as a guide for the provision of reproductive health services at the beginning of a humanitarian crisis. The goal of MISP was to outline the services that people in humanitarian crises are to receive to minimize injury and death from complications related to reproductive health, prevent and manage the consequences of sexual violence, and reduce the transmission of sexually transmitted infections, or STIs. The MISP recognizes that reproductive health is a human right that applies to people in humanitarian crises, and provides specific details for governments and agencies to follow so they can mitigate the adverse effects of reproductive health issues in vulnerable populations.

MISP, which is a part of Reproductive Health in Refugee Situations: An Inter-agency Field Manual, hereafter the Manual, presents specific guidelines for governments and agencies to follow during humanitarian crises to protect the reproductive health of refugees. According to the United Nations, refugees are individuals who face humanitarian crises, fleeing their homes and seeking refuge, or shelter, in another country. The Manual specifically details the reproductive health of refugees. Also, the Manual promotes reproductive justice, which allows people to adequately practice sexual health and have the freedom to decide if and when to become pregnant. Comprehensive reproductive health services are essential to reproductive justice. Reproductive health services include access to quality health care during and after pregnancy, treatment for diseases of the reproductive organs and for sexually transmitted infections, or STIs, and sexual health education. MISP serves as a guide for governments and agencies who respond to humanitarian crises to provide those comprehensive reproductive health services to refugees.

The IAWG was established in 1995, following an Inter-agency Symposium on Refugee Situations that took place in Geneva, Switzerland. The IAWG included members that represented various governments, agencies, researchers, and donor organizations. Members of the United Nations International Children’s Fund, or UNICEF, United Nations High Commissioner for Refugees, or UNHCR, United Nations Population Fund, or UNFPA, and the World Health Organization, or the WHO, represented international governments. Members from the Centers for Disease Control and Prevention, or the CDC, and the US Department of Health and Human Services also participated on the committee, representing the US government. The IAWG originally released the first draft of MISP in 1996 and then tested its effectiveness in humanitarian crises. In the Manual, IAWG details the findings of those tests and found specific reproductive health challenges, including sexual violence, transmission of STIs, and pregnancy complications, among refugees in seventeen different countries. The IAWG published the official version of MISP in 1999.

The IAWG divides MISP into five sections. In the first section, the IAWG states that there is a need for governments and agencies that respond to humanitarian crises to identify a lead organization that should be responsible for coordinating and implementing reproductive health services. Following that, in the second section, the IAWG recognizes that the prevalence of sexual violence increases during humanitarian crises. So, the IAWG makes recommendations to prevent sexual violence and provide services to women who are victims of sexual violence. Then, in the third section, the IAWG recommends that governments and agencies supply free condoms to prevent the spread of human immunodeficiency virus, or HIV, which is a sexually transmitted virus that damages the immune system. In the fourth section, because humanitarian crises include women at various stages of pregnancy, the IAWG suggests that governments and agencies work to prevent the death of pregnant women and their neonates during childbirth by providing clean delivery kits. Lastly, in the fifth section, the IAWG recommends that governments and agencies create plans to integrate comprehensive reproductive health services as soon as possible.

The IAWG begins MISP by stating that individual governments and agencies should not have to assess the needs of specific humanitarian crises before implementing MISP's guidelines because MISP was created with those needs in mind. The IAWG states that the purpose of MISP is more than a list of equipment and supplies that governments and agencies need at the onset of a humanitarian crisis. Rather, the IAWG asserts that MISP is a set of activities that appropriately trained staff should implement during humanitarian crises. The IAWG also stipulates that those activities should focus on reproductive health. Additionally, the IAWG states that at the beginning of any humanitarian crisis, governments and agencies that respond to crises should identify a lead organization that is responsible for coordinating and implementing reproductive health services. According to the IAWG, the lead organization should also identify a specific person to be in charge of coordinating the necessary reproductive health services. That person, the IAWG argues, should have experience in reproductive health challenges, be sensitive to cultural, ethical, or religious diversity, and should work as the lead coordinator for at least six months. The authors state that six months is the estimated amount of time that it should take governments and agencies to establish comprehensive reproductive health services.

In the second section of MISP, the IAWG recognizes that sexual violence increases during humanitarian crises and recommends that governments and agencies prevent sexual violence and provide services to women who are victims of sexual violence. To prevent sexual violence, the IAWG suggests that governments and agencies should design refugee camps, which is where refugees often live during humanitarian crises, with input from refugees to enhance the physical safety of refugees. The authors recommend that to increase the physical safety of refugees, specifically women, governments and agencies should station female protection staff, health care providers, and translators in refugee camps. The IAWG further recommends that governments and agencies should identify households with minors, or children who are under the age of eighteen years, because the IAWG states that those minors may be at a higher risk of sexual violence.

In the third section, the IAWG recommends that governments and agencies should supply free condoms to prevent the spread of the of HIV. Specifically, the IAWG recommends that governments and agencies provide free condoms and ensure that refugees know of multiple places where they may get free condoms. Condoms, when used correctly and consistently can reduce the spread of HIV, as well as other STIs.

In the fourth section, understanding that humanitarian crises will include women at various stages of pregnancy, the IAWG recommends that governments and agencies work to prevent the death of pregnant women and their neonates during childbirth. To mitigate that risk of death, the authors recommend that governments and agencies provide what they refer to as simple delivery kits to pregnant women and traditional birth attendants, for deliveries that happen outside a healthcare facility. Traditional birth attendants are people who assist pregnant women during childbirth. The IAWG states that the simple delivery kit should contain a bar of soap, one plastic sheet to use as a clean surface for a pregnant woman to lay on during childbirth, one clean razor blade to cut the umbilical cord once the neonate leaves the birth canal, and two pieces of string to tie the umbilical cord. During pregnancy, the umbilical cord connects the fetus to the placenta, which provides essential nutrients to the fetus. The authors state that the UNFPA supplies the simple delivery kits.

Continuing in the fourth section, for pregnant women with complicated childbirth, the IAWG recommends that government and agencies refer those women to a refugee-specific health care facility within the country that the women sought refuge in. According to the IAWG, approximately fifteen percent of births in humanitarian crises will result in complications. Those complications may result from malnutrition and infectious diseases. The IAWG requests that those countries’ governments set up refugee-specific health care facilities where pregnant women can receive appropriate care for any complications. The IAWG further recommends that governments and agencies should use the New Emergency Health Kit 98, or the NEHK-98 Kit, to provide proper health care in emergency cases. According to the IAWG, the NEHK-98 Kit contains several provisions that are necessary for complicated childbirths. The United Nations Internationals Children’s Emergency Fund, or UNICEF, provides the NEHK-98 Kits, which are specifically for health care professionals rather than pregnant women or traditional birth attendants. The NEHK-98 Kit contains medications, including gentian violet, which treats fungal infections, and paracetamol which reduces pain and fever. Also, the NEHK-98 Kit contains equipment such as forceps to assist in the delivery of neonates and ballpoint pens and A6 notepads to record the outcome of the delivery.

Lastly, in the fifth section, the IAWG suggests that governments and agencies plan to integrate comprehensive reproductive health services as soon as possible. The authors recommend that governments and agencies collect information about how many pregnant women and neonates have died during or after delivery, and how many individuals have tested positive for HIV. The authors argue that information about the number of HIV and STI-positive individuals will help governments and agencies determine how many refugees need reproductive health services and the specific type of services that are needed in humanitarian crises.

Since publishing MISP in 1999, implementation of the IAWG’s recommendations in humanitarian crises has been inconsistent, with humanitarian staff either being unaware of or not following the IAWG's guidelines. For example, a study that examined humanitarian crises between 2000 and 2010 found that in 2003, humanitarian staff failed to implement the IAWG’s recommendations in Afghanistan, leaving refugees at risk of contracting HIV. Also, during a humanitarian crisis in Chad in 2004, only two out of every six humanitarian staff knew about MISP. Likewise, the study also found that in the aftermath of a 2010 earthquake in Haiti, only half of the humanitarian staff knew about the objectives of MISP.

In 2010, the IAWG released an updated version of MISP. In the 2010 version, the IAWG includes more details to each section of the original version of MISP. For example, on the topic of sexual violence in the second section, the IAWG includes principles that governments and agencies should use when they respond to the needs of survivors of sexual violence. Those principles include respecting and not discriminating against survivors, as well as ensuring their safety and confidentiality. The IAWG then includes details about how to collect forensic evidence if a survivor of sexual violence wishes to pursue a legal case against their perpetrator.

Despite inconsistent implementation of the IAWG’s guidelines in humanitarian crises, MISP outlines the essential reproductive health services that governments and agencies ought to provide to people during those crises. As of 2021, governments and agencies continue to work to provide refugees the services outlined in MISP to minimize injury and death due to pregnancy complications, prevent and manage the consequences of sexual violence, reduce the transmission of STIs, and plan for the future provision of comprehensive reproductive health services.