Reproductive health coordination gap, services ad hoc: Minimum initial service package (MISP) assessment in Kenya


Executive Summary

The post-election violence in Kenya in the early months of 2008 displaced more than 500,000 people. In any humanitarian crisis, certain priority reproductive health (RH) services must be put in place from the earliest stages of an emergency. These essential activities are defined in the Minimum Initial Services Package (MISP)-the established international standard for providing RH care in emergencies. They include activities to prevent sexual violence and treat survivors; protect against the transmission of HIV; ensure delivery supplies and emergency care for pregnant women and newborns; and lay the groundwork for comprehensive RH services once conditions allow. The Women's Commission for Refugee Women and Children (Women's Commission) undertook a mission to Kenya in April 2008 to assess the progress the humanitarian community has made in the institutionalization of the MISP in emergency response operations. The assessment took place four months after the crisis erupted and included visits to camp settings in the Nairobi, Kisumu, Kitale, Eldoret and Nakuru regions.

Key Findings

1) Despite the ongoing and urgent needs of large numbers of displaced persons, the Women's Commission found that funding was clearly inadequate to meet the unaddressed health needs of the displaced. UN emergency appeals to address humanitarian needs related to the post-election violence remained significantly underfunded at the time of the assessment, and organizations that could have continued to respond were bringing their emergency response operations to a close.

2) The most significant and overarching gap in the implementation of the MISP was the absence of RH coordination at all levels.

3) Awareness of the MISP among humanitarian workers in Kenya was higher than awareness levels registered in two earlier MISP assessments conducted by the Women's Commission. However, the MISP was not guiding action in Kenya which meant there were still unacceptable gaps in protection and key RH services.

4) Planning to prevent high levels of sexual violence, inlcuding sexual exploitation and abuse, were strong at the national level but still inadequate at the field level. Poor security measures were noted at all but one camp and the assessment team received numerous disturbing reports of sexual exploitation and abuse by humanitarian workers, police and others.

5) Mechanisms to respond to sexual violence, inlcuding sexual exploitation and abuse, were also weak at the field level. Displaced persons and representatives of humanitarian organizations reported a general atmosphere of impunity toward perpetrators of sexual violence. Health workers also suggested that many of the displaced did not know the importance of seeking treatment for sexual assault or where it was offered. Many displaced women were only slowly seeking care months after the height of the violence.

6) In terms of priority activities taken to protect against HIV transmission, the findings were mostly positive. It was encouraging that health care providers were concerned from the start of the crisis about the need to prevent the transmission of HIV and to ensure people living with AIDS had continuing access to antiretroviral medicines. By all accounts, there were sufficient supplies of male condoms; however, some displaced persons reported that they were still not freely available or easy to obtain.

7) The Women's Commission found that referral systems to care for pregnancy-related emergencies were not uniformly in place, and transportation for women and girls suffering from complications of their pregnancy or delivery was highly problematic in some places. While clean delivery kits were available in some settings, they were not consistently distributed to visibly pregnant women and there were shortages in some settings. In addition, no displaced women we spoke with were aware of or had heard of clean delivery kits.

8) Young people appeared to be the most severely affected, with many reporting idleness due to a lack of jobs and opportunities to attend secondary school and university. In addition, young people noted that the sudden movement from their busy lives in rural areas to overcrowded urban camps where they were now idle created more exposure to the opposite sex. A sudden increase in sexual activity enhanced their vulnerability to sexually transmitted infections, including HIV, and unwanted pregnancies.

Although the Kenya crisis has disappeared from the headlines, daily life remains a crisis for people who are still displaced from their homes and communities. The Kenyan government and international aid agencies must take immediate and coordinated action to address the priority RH needs of the displaced populations. In particular, the needs of young people should be prioritized considering their vulnerability to sexual exploitation and abuse and heightened risk of unsafe sex as they remain displaced or return to their homes.

More broadly, this assessment highlights the need for a deeper commitment on the part of donors and the humanitarian community to the institutionalization of the MISP in humanitarian crises, particularly to ensure RH coordination from the beginning of an emergency. Adequate funding for MISP activities must be provided at the onset of an emergency, and more humanitarian workers must be trained and skilled in MISP implementation.