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

2. Outline • Introduction • Objectives • Methods • Context • Preliminary Findings • Recommendations • Next Steps

3. Introduction Global Evaluation • Literature review • MISP assessment (Jordan) • In-depth assessment • Coverage study in the in-depth assessment sites • Agency commitment study • Health information system • Funding analysis

4. 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.

5. 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.

6. 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.

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

8. Context • 366,212 Syrian refugees in Jordan (425,771 and 65,040 unregistered) • 168,468 refugees in Zaatri Camp (192,193) • 133,660 refugees in urban areas(169,538) • Ongoing humanitarian crisis • ~1,500/day influx

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

10. Credit: Sandra Krause/WRC

11. 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.

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

13. Credit: UNFPA

14. 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.

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

16. Preliminary findings related to the MISP 1) Coordination of the MISP • Positive impressions. • Need for further focus on urban areas. 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.

17. Preliminary 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.

18. Preliminary 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 (except some methods) for married couples. • Lack of protocols for STI care. • ARVs very limited. • Gap in menstrual hygiene supplies.

19. Limitations • Time and security • Minimal field time • Very preliminary analysis • FGD participants found it difficult to focus on RH questions

20. 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.

21. 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.

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

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!