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The Minimum Initial Service Package (MISP) for Sexual and Reproductive Health (SRH) is a set of lifesaving priority activities to be implemented from the onset of a crisis. These services are to be scaled up and sustained to ensure equitable coverage throughout protracted crises and recovery while planning to integrate comprehensive SRH into primary health care as soon as possible.

Morbidity and mortality related to SRH are significant issues, and women and girls in humanitarian emergencies suffer disproportionately from life-threatening conditions due to increased barriers to health services.1 Neglecting SRH needs in humanitarian settings has serious consequences, including preventable maternal and newborn morbidity and mortality; preventable consequences of unintended pregnancy, such as unsafe abortion; and preventable cases of sexual violence and their consequences, including unintended pregnancies, increased acquisition of sexually transmitted infections (STIs), increased transmission of the human immunodeficiency virus (HIV), and ongoing mental health problems, including depression.

The MISP defines which SRH services are most important in preventing morbidity and mortality while protecting the right to life with dignity in humanitarian settings. It is a standard for humanitarian actors and is supported by the international legal obligations of states to respect and ensure basic human rights, including SRH. All people, including those affected by crises, have a fundamental human right to SRH. To exercise this right, affected populations must have an enabling environment and access to SRH information and services so that they can make free and informed choices. The MISP for SRH services provided during a humanitarian emergency must be based on the needs of the crisis-affected populations, must respect their religious and ethical values and cultural backgrounds, and must conform to international human rights and humanitarian standards.

Despite being an internationally recognized standard, assessments undertaken by the Women’s Refugee Commission and partners in 20032, 3, 20044, and 20055 showed that implementation of the MISP for SRH was often overlooked during emergencies and few humanitarian workers were familiar with its objectives and activities. Since then, progress has been made in advancing awareness of the MISP for SRH. In September 2009, the Granada Consensus was agreed upon through an inter-agency consultation convened by the United Nations Population Fund, World Health Organization, and the Andalusian School of Public Health, providing a new commitment and framework for action. A key component of the Granada Consensus was scaling up equitable coverage of the MISP for SRH and sustaining these services in protracted crises and throughout recovery, while integrating comprehensive SRH services through health systems strengthening.6 Inter-agency assessments in 2007 and 2010 demonstrated an increased awareness of the priority SRH services of the MISP for SRH that should be implemented; however, the services were not systemically available.7

In 2013 and 2015, inter-agency assessments of crisis settings found consistent availability of MISP for SRH services and high awareness of the MISP for SRH as a standard among responders.8 An inter-agency MISP for SRH assessment in Jordan in 2013, following the influx of Syrian refugees, demonstrated increased recognition and support of the MISP for SRH through strong leadership by the Ministry of Health, United Nations agencies, and nongovernmental organizations. Coordination was appropriate at the national and camp levels but insufficient in urban areas where beneficiary participation and knowledge of services were lacking.9 Two years later, in the 2015 assessment in Nepal following the earthquake, sizeable advances had occurred; the SRH working group (SRH sub-cluster) was established within days of the earthquake, funding and supplies were sufficient, and there was a strong awareness of the MISP for SRH among humanitarian practitioners. Commitments and investments in SRH before the crisis, the existence of the MISP for SRH in preparedness activities, and the pre-positioning of Inter-Agency Emergency Reproductive Health Kits were key factors to the success. The main limitations of the Nepal MISP for SRH response included a slower activation of district-level coordination and a lack of community knowledge about SRH issues, including the benefits of seeking care and the locations of services for sexual violence, STIs, and HIV. Following the assessment, the Nepal National Family Planning Costed Implementation Plan (2015–2020) was established, and central- and district-level MISP for SRH trainings were held to mainstream the MISP for SRH into district disaster preparedness and response plans.10

These are some examples of the achievements made over the years in ensuring the availability of the MISP for SRH at the onset of humanitarian responses. Although much progress has been made, more effort is required to guarantee its universal implementation in acute crises. The Women’s Refugee Commission and the IAWG’s Minimum Initial Service Package for Sexual and Reproductive Health in Crisis Situations: A Distance Learning Module is a resource and tool that provides guidance on the implementation of quality MISP for SRH services and raises awareness about the importance of addressing priority SRH services in crisis settings.

  1. Maternal Mortality in Humanitarian Crises and Fragile Settings (United Nations Population Fund, November 2015), https://www.unfpa. org/resources/maternal-mortality-humanitarian-crises-and-fragile-settings.
  2. Still in Need: Reproductive Health Care for Afghan Refugees in Pakistan (Women’s Refugee Commission, October 2003),https://www.womensrefugeecommi...
  3. Displaced and Desperate: Assessment of Reproductive Health for Colombia’s Internally Displaced Persons, Marie Stopes International and Women’s Refugee Commission, (Reproductive Health Response in Crises Consortium, February 2003), https://www. womensrefugeecommission.org/srh-2016/resources/72-displaced-and-desperate-assessment-of-reproductive-health-for-colombia-s-internally-displaced
  4. Lifesaving Reproductive Health Care: Ignored and Neglected, Assessment of the Minimum Initial Service Package (MISP) for Reproductive Health for Sudanese Refugees in Chad (Women’s Refugee Commission and United Nations Population Fund, August 2004), https://www.womensrefugeecommi...
  5. Reproductive Health Priorities in an Emergency: Assessment of the Minimum Initial Service Package in Tsunami-Affected Areas in Indonesia (Women’s Refugee Commission, February, 2005) https://www.womensrefugeecommission.org/images/zdocs/id_misp_eng. pdf.
  6. Sexual and Reproductive Health During Protracted Crises and Recovery: Report on an Expert Consultation Held in Granada, Spain, 28–30 September 2009, Preliminary Publication (World Health Organization, 2010).
  7. Four Months On: A Snapshot of Priority Reproductive Health Activities in Haiti: An Inter-Agency MISP Assessment Conducted by CARE, International Planned Parenthood Federation, Save the Children and the Women’s Refugee Commission May 17–21, 2010 (Women’s Refugee Commission, October 2010).; Reproductive Health Coordination Gap, Services Ad Hoc: Minimum Initial Service Package (MISP) Assessment in Kenya (Women’s Commission for Refugee Women and Children, September 2008), https://www.womensrefugeecommi...
  8. Sandra K. Krause, Sarah K. Chynoweth, and Mihoko Tanabe, “Sea-Change in Reproductive Health in Emergencies: How Systemic Improvements to Address the MISP Were Achieved,” Reproductive Health Matters, 25, no. 51, (December 13, 2017): 7–17, DOI: 10.1080/09688080.2017.1401894.
  9. Sandra Krause, Holly Williams, Monica A Onyango, Samira Sami, Wilma Doedens, Noreen Giga, Erin Stone and Barbara Tomczyk, “Reproductive Health Services for Syrian Refugees in Zaatri Camp and Irbid City, Hashemite Kingdom of Jordan: An Evaluation of the Minimum Initial Services Package,” Conflict and Health 9, Suppl 1 (February 2, 2015): S4, http://www.conflictandhealth.c...
  10. Anna Myers, Samira Sami, Monica Adhiambo Onyango, Hari Karki, Rosilawati Anggraini, and Sandra Krause “Facilitators and barriers in Implementing the Minimum Initial Services Package (MISP) For Reproductive Health in Nepal Post-Earthquake,” Conflict and Health 12, no. 35 (August 15, 2018), https://doi.org/10.1186/s13031-018-0170-0.