Conducted by the Inter-agency Working Group on RH in Crises

1. Evaluation of the Implementation of the Minimum Initial Service Package (MISP) for Reproductive Health among Syrian Refugees in Irbid City and Zaatri Camp, Jordan Conducted by the Inter-agency Working Group on RH in Crises Sandra Krause/Women’s Refugee Commission Holly Williams/CDC Samira Sami/CDC Monica Onyango/Boston University Wilma Doedens/UNFPA * Basia Tomczyk * Seven local staff

2. MISP Evaluation: Objectives • Assess the extent to which MISP has been implemented in Irbid City and Zaatri Camp. • Identify the availability, accessibility, and use of MISP services. • Describe facilitating factors and barriers to the implementation of MISP services.

3. MISP Evaluation • Inter-agency preparatory work • Institutional Review Board (Human Subjects Protection) approval by CDC • Field work: 17 – 21 March 2013 • Mixed methods • Key informant interviews • Health facility assessments • Focus group discussions

4. Context • 355,493 Syrian refugees in Jordan • 298,025 registered • 57,468 unregistered refugees in urban areas • 164,365 Zaatri camp • 133,660 Urban areas • 15.8% in Irbid City (n=47,087) • 13.2% in Amman • Ongoing humanitarian crisis • ~1,500/day influx

5. Context Specific to Irbid City • Ministry of Health • Non-governmental organizations Credit: UNFPA Credit: Sandra Krause/WRC Credit: Sandra Krause

6. Credit: Jeff J Mitchell/Getty Images, The Guardian

7. Context Specific to Zaatri Camp • High level of medical care. • Low level of community engagement and primary health care. Credit: UNFPA

8. MISP Objectives Ensure the health sector/cluster identifies an organization to lead implementation of the MISP. Prevent and manage the consequences of sexual violence. Reduce HIV transmission. Prevent excess maternal and newborn morbidity and mortality. Plan for comprehensive RH services as the situation permits.

9. Additional priorities of the MISP Ensure contraceptives are available to meet the demand. Ensure treatment of sexually transmitted infections (STIs) is available. Ensure antiretrovirals (ARVs) are available to continue treatment for people already on ARVs including for prevention of mother to child transmission. Distribute culturally relevant menstrual protection materials to women and girls.

10. Methods • Key informant interviews (11) + 6 • Health and RH managers, coordinators directors • MOH, UN agencies, NGOs • Health facility assessments • Zaatri camp (5 including: 2 hospitals; 1 health center; 2 clinics) + referral hospital • Irbid city (7 including: 2 hospitals; 2 health centers; 2 clinics; and 1 blood bank)

11. Methods Continued • Focus group discussions (Syrian women 18-49 years) • Assess attitudes and knowledge about RH and access to services • 101 women in Zaatri camp • 58 women in Irbid City

12. Findings related to the MISP 1) Coordination of the MISP • Lead RH organization (MOH/UNFPA) • Designated RH officer for the emergency • RH Coordination meetings • Funding and supplies (RH Kits) 2) Prevent and manage sexual violence • Camp: inadequate lighting in camps and distance to services. Urban: distance to schools. • Limited availability and knowledge of clinical services.

13. Findings related to the MISP (cont) 3) Reduce HIV Transmission • Safe blood transfusion. • Standard precautions are generally in place. • Condoms available but access is restricted. 4) Prevent maternal and newborn morbidity/mortality • Skilled birth attendants are available. • Basic/Comprehensive emergency obstetric and newborn care available. • 24/7 referral services established but limited. • Negative perceptions by community of health services. • Distribution of clean delivery kits not implemented.

14. Findings related to the MISP (cont) 5) Planning for Comprehensive RH Services • Gap in background data for RH. • Sites for future RH services are in process. 6 ) Additional Priorities • Strong desire for family planning: generally available for married couples. • Lack of protocols for Clinical Care for Survivors and STI care. • ARVs very limited. • Gap in menstrual hygiene supplies.

15. Priority Concerns of Refugee Women and Girls in Zaatri Camp • Desire to be treated with dignity and respect. • Hygiene • Toilets: maintenance, not sex-specific. • Lack of clean water. • Major desire for hygiene and cleaning products. • Inequitable distributions. • Lack of supervision of community/street leaders. • Strong perception of no outreach from agencies. • Inability to work or volunteer. • Reported increase in domestic violence.

16. Priority Concerns of Refugee Women and Girls in Irbid City • High rent and utility costs. • Inability to work. • Inequitable distribution and need for UN supervision. • Strong need for UN card to improve quality of life. • More flexibility related to purchases with vouchers. • Strong tensions with host community.

17. Key Facilitating Factors to MISP Implementation • Government of Jordan’s pre-existing level of infrastructure, health care system and willingness to address RH among Syrian refugees • Dedicated lead agency and RH focal point in the health sector • Adequate RH materials and supplies • Donor support for the MISP • Capacity Development through prior • MISP training’s

18. Key Barriers to MISP Implementation • Lack of adequate focus to urban areas • Lack of adequate staff in urban areas • Lack of protocols for care for survivors of sexual violence and sexually transmitted infections. • Limited community outreach • Lack of sufficient funding; limited supplies distribution

19. Limitations • Cross-sectional – limits comparison to different points in time • Context of an ongoing emergency with large influxes to study areas • Challenges with KII and Health Facility Study tools. • Lack of experience of data collectors and time to train them • Participants chosen by NGO staff did not always meet age inclusion criteria

20. Conclusion: Progress and Gaps Progress • Health and RH directors, managers and coordinators were largely knowledgeable of MISP objectives and priority activities • MISP services and key elements to support implementation of the MISP were largely in place, including a dedicated lead agency to support MISP implementation within the health sector, a focal point for RH coordination, regular RH coordination meetings in Amman and Zaatri camp, and RH kits and supplies, and funding for MISP implementation. • Lead agencies (MOH; UNHCR and UNFPA) in health and reproductive health demonstrate concerted effort to address the MISP and CRH.

21. Conclusion: Progress and Gaps Gaps • Urban areas received less attention in coordination initiatives along with reported challenges in human resource capacity. •  Health and RH directors, managers and coordinators had very limited understanding of the additional priorities of the MISP. • Women and girls were dissatisfied with the quality of care in Zaatri camp.

22. Conclusion: Progress and Gaps Gaps • Clinical care for survivors of sexual violence was very limited: Women and girl’s and service provider’s knowledge of these services were low. • Lack of basic necessities including sanitation supplies. • Gap in provider and beneficiary interface e.g. lack of community engagement and information sharing; poor provider-client interactions • Contingency plans were developed but not activated. • Gap in systematic RH indicator collection at facilities in Zaatri

23. Acknowledgements • Jordanian Ministry of Health • UNHCR • UNFPA • IRC • Jordanian Women’s Union • Gynecologue Sans Frontieres (GSF) • Royal Medical Services (RMS) • Jordan Health Aid Society (JHAS)–Women’s Clinic • Physicians Across Continents (PAC) • Moroccan Field Hospital (MFH) • Marfraq Hospital • IFH Noor Al Hussein Foundation • Amman Jordan Association • IMC • MDM • Medair • UNAIDS • International Relief & Development • WHO • Save the Children • MISP Evaluation Translators

24. Thank You!

25. Recommendations • Scale up efforts to ensure basic needs for reproductive health are being met through the provision of hygiene products. • Implement safety measures to protect women and children from violence, such as safe transport to schools in Irbid City and adequate lighting and sex-specific latrines in Zaatri Camp. • Scale up the availability of care for survivors, particularly in urban areas and that all health care providers and protection staff are informed about the availability and location of care for survivors.

26. Recommendations (cont) • Develop culturally appropriate mechanisms for improving knowledge about the benefits of seeking care and available clinical services for survivors of sexual violence. • Undertake culturally appropriate methods to inform the community of where to access free condoms and other forms of family planning. • Ensure the availability of and access to emergency obstetric and newborn care 24 hours a day, seven days a week.

27. Next Steps • Global evaluation: advocate findings in advance of: • International Conference on Population and Development (ICPD) + 20 • Millennium Development Goals (MDGs) • Develop beneficiary and field partner reports.