Providing Reproductive Health Care to Internally Displaced Persons: Barriers Experienced by Humanitarian Agencies

Abstract

Reproductive health care for internally displaced persons (IDPs) is recognised by the Inter-Agency Working Group on Reproductive Health in Refugee Situations and the Reproductive Health Response in Conflict Consortium as a neglected area in humanitarian relief operations. To identify barriers to agencies providing reproductive health care to IDPs, and their strategies for overcoming these barriers, we interviewed representatives of 12 relief and development agencies providing health care to conflict-affected populations. Although material and human resources are significant constraints on agencies, the main challenge is to tackle ideological, managerial and policy barriers, and those related to donor influence. The absence of a legal instrument that recognises IDPs internationally has contributed to the difficulties agencies face in systematically reaching IDPs. Our findings suggest that considerable efforts are needed to close the gap between international commitments and the provision of services at field level. We recommend that agencies carry out awareness-raising activities internally and among partner organisations and donors, strengthen internal organisation and inter-agency collaboration and share expertise in order to maximise benefits and save resources at the local level. We also recommend exploring the possibility of an international convention to protect the rights of internally displaced persons.

Résumé

Le Groupe de travail interinstitutions sur la santé génésique dans les situations de réfugiés et le Consortium Reproductive Health Response in Conflict considèrent que les soins de santé génésique pour les personnes déplacées à l’intérieur de leur propre pays sont un domaine négligé des opérations humanitaires. Pour identifier les obstacles qui empêchent les institutions d’assurer des soins de santé génésique en faveur des déplacés et leurs stratégies pour surmonter ces obstacles, nous avons interrogé des représentants de 12 institutions de secours et de développement apportant des soins de santé à des populations touchées par des conflits. Bien que les institutions soient limitées par les ressources humaines et matérielles, elles sont surtout gênées par des obstacles idéologiques, politiques, de gestion et liés à l’influence des donateurs. L’absence d’un instrument juridique reconnaissant les personnes déplacées dans leur propre pays au niveau international aggrave les difficultés des institutions pour desservir systématiquement les personnes déplacées. Nos conclusions suggèrent que des efforts considérables sont nécessaires pour combler l’écart entre les engagements internationaux et la prestation des services sur le terrain. Nous recommandons aux institutions de sensibiliser leurs collaborateurs ainsi que les organisations partenaires et les donateurs, de renforcer l’organisation interne et la collaboration interinstitutions et de partager les compétences pour maximaliser les avantages et économiser des ressources au niveau local. Nous conseillons également d’étudier la possibilité d’une convention internationale pour protéger les droits des personnes déplacées.

Resumen

Los servicios de salud reproductiva para personas desplazadas internamente (PDI) son reconocidos por el Grupo de Trabajo Interinstitucional sobre Salud Reproductiva en Situaciones con Refugiados y el Consorcio de Respuesta a la Salud Reproductiva en Conflicto como un área descuidada en las actividades de socorro. A fin de determinar las barreras a las instituciones que proporcionan servicios de salud reproductiva a las PDI, así como sus estrategias para vencer estas barreras, entrevistamos representantes de 12 instituciones de socorro y desarrollo que proporcionan servicios de salud a poblaciones afectadas por conflicto. Aunque los recursos materiales y humanos son considerables limitaciones para las instituciones, el reto principal es afrontar las barreras ideológicas, administrativas y políticas, así como aquellas relacionadas con la influencia de los donantes. La ausencia de un instrumento jurídico que reconozca las PDI internacionalmente ha contribuido a las dificultades de las instituciones para alcanzarlas de manera sistemática. Nuestros hallazgos indican que se necesitan esfuerzos considerables para salvar la distancia entre los compromisos internacionales y la prestación de servicios en el campo. Recomendamos que las instituciones realicen actividades de concienciación internas y entre organizaciones colaboradoras y donantes, fortalezcan la colaboración interna e interinstitucional y compartan conocimientos y experiencia a fin de maximizar los beneficios y ahorrar recursos a nivel local. Además, recomendamos explorar la posibilidad de una convención internacional para proteger los derechos de las personas desplazadas internamente.

Key Words:

• reproductive health services
• internally displaced persons
• humanitarian assistance
• donor funding and assistance

Reproductive health care for conflict-affected populations has long been a neglected public health issue, and the needs of internally displaced persons (IDPs) in particular have largely been overlooked.^1–3 The Guiding Principles on Internal Displacement by the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) define IDPs as people “who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalised violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognised State border”.⁴

While refugees, who have by definition crossed an international border, are protected under the Convention relating to the Status of Refugees, 1951, there is no legal instrument recognising IDPs internationally;¹ nor are IDPs included in the original mandate of the United Nations High Commissioner for Refugees (UNHCR). This has prevented agencies from tackling the problem systematically, leaving IDPs in a vulnerable position.^5–7 Agencies find it difficult to reach the currently 25 million IDPs worldwide,^5,8–11 and while refugees nowadays have relatively good access to health interventions, IDPs are largely excluded, despite their increasing number in the world.¹²

The majority of the world’s IDPs are found in Africa (12 million).¹⁰¹¹ IDPs are a heterogeneous group, whose characteristics are defined by the country in which they live, the type and phase of conflict and their living conditions – that is, whether they live in camps, mix with local populations or are dispersed and hidden from national authorities and international agencies.⁷ National governments sometimes have hostile attitudes towards IDPs, forcing them to flee to unknown or remote areas.⁵ IDPs can be dispersed in various places, making identification and targeting difficult due to volatile security situations, infrastructure collapse and restricted access to remote areas.^1,13 In contrast to dispersed IDPs, those living in camps may to some extent benefit from similar health interventions as refugees, as they are often cared for by humanitarian agencies and tend to have some access to primary health care.^1,14–16 It is more difficult for national health authorities and humanitarian agencies to reach dispersed IDPs.

Most IDPs do not have access to comprehensive reproductive health care,^13,17,18 and national authorities are sometimes neglectful of their reproductive health needs, despite having responsibility for their protection.^1,4,15 However, IDPs have reproductive health needs like everybody else and may need additional services, for instance as victims of gender-based violence.^1,16,19 Furthermore, IDPs experience loss of income and breakdown of family support networks, which lead to increased physical and emotional burden and lack of traditional sources of assistance and protection.²⁰ One major reason for this neglect is the common perception that, in conflict situations, reproductive health is less important than other health needs; another is the weakening political support for reproductive health programmes more broadly.¹³

Donors have been reluctant to intervene, forcing agencies to compete for limited funds.²¹ Donor funding has generally decreased since 2000,^5,22–24 with the exception of the US Agency for International Development, European Union, UK Department for International Development, Andrew Mellon Foundation and UNFPA’s special fund for reproductive health programmes for refugees.²¹

Nevertheless, positive developments have been observed in implementing reproductive health programmes since 1995, largely due to the efforts of the International Conference on Population and Development 1994, the Inter-Agency Working Group (IAWG) and the Reproductive Health in Conflict Consortium (RHRCC).^1,8,25,26 Reproductive health as a basic human need has been acknowledged by an increasing number of humanitarian agencies and the international community,^1,27 and sections on reproductive health have been included in guidelines developed to facilitate care for conflict-affected populations. UNOCHA’s Guiding Principles on Internal Displacement, ⁴ the Sphere Handbook by the Steering Committee for Humanitarian Response,²⁸ and IAWG’s Minimum Initial Service Package ²⁰ specifically address these. Other mechanisms to improve inter-agency collaboration in situations of emergency and internal displacement have also been established, such as the “Cluster Leads Approach”, whereby one agency takes the lead for a given sector, such as health, to strengthen inter-agency field-level coordination.²⁹³⁰

IAWG and RHRCC have called for an increase in the capacity of humanitarian agencies to provide reproductive health services to IDPs.^1,14 In response to this call, we carried out a qualitative study in 2005 to examine the barriers encountered by relief and development agencies to providing reproductive health care to IDPs in conflict situations, as well as the agencies’ strategies for overcoming these barriers.³¹

Methods and participants

We contacted relief and development agencies providing reproductive health care to conflict-affected populations, or health services other than reproductive health, or a range of services including health care. Due to resource constraints, agencies have their headquarters in industrialised countries, and English or French as working languages. 114 eligible agencies were identified from the IAWG member list, participants’ lists of relevant conferences, documents from expert sources and relevant websites, and through personal recommendations. They consisted of 107 NGOs, and seven multilateral/government agencies; of these, 84 were non-denominational, 29 were Christian, and one was Muslim. A questionnaire was e-mailed to them to gather baseline information about their reproductive health service provision to IDPs, and to invite them to participate in a semi-structured telephone interview on these issues. Due to absence of staff in charge (64%), no suitable respondent identifiable (12%) and explicit unwillingness to participate (10%), 99 agencies did not participate.

Fifteen agencies agreed to participate by way of questionnaire and telephone interview. Twelve interviews were eventually carried out with 11 NGOs and one multilateral/government agency, all of them already involved with IDPs living in or outside camps, or with reproductive health. Three of the 15 could not be interviewed due to the absence of the respondent during the interview period.

Three of the 12 agencies interviewed were based in the US, eight in Europe and one in Canada; nine were non-denominational and three were Christian faith. All 12 agencies operated in Africa, eight in Asia, six in Latin America, five in the Middle East and four in Europe. Interviewees included three directorial-level staff and nine in managerial or advisory positions from headquarters and the field. Eleven interviewees were in charge of conflict-affected populations, five of reproductive health and ten of overall health issues.

The types of reproductive health services to be addressed in the interview were selected from the Minimum Initial Service Package²⁰ and the Sphere Handbook.²⁸ They included antenatal care, essential obstetric care, prevention and response to sexual and gender-based violence, prevention and treatment of sexually transmitted infections, prevention of mother-to-child transmission of HIV, family planning and special reproductive health care for young people and men. The selection of reproductive health services addressed in the interviews proved appropriate; one additional service, the management of vesico-vaginal fistula, was suggested by one agency.

We used thematic content analysis to identify recurrent themes and their relationships.³²³³ The ethics committee of the London School of Hygiene and Tropical Medicine approved the study. The names of the agencies and individuals are treated as confidential.

Findings

Thematic content analysis allowed the classification of themes into four groups, and under those themes barriers to provision of services and strategies for overcoming them (Table 1). While insufficient material and human resources issues considerably constrain the agencies, it was the more abstract issues of international policy, agency mandate and philosophy, internal management, prioritisation of other services and the complexity of collaboration with partners that were identified as the most challenging barriers to overcome. As a matter of definition, collaboration barriers related to sharing of tasks, resources and costs between expert agencies or local groups, setting common goals, developing joint programming and norms, and writing joint assessments and reports.

short-legendTable 1

In sum, these abstract barriers often reflect the ideological, managerial and competitive choices and awareness level of agencies, affecting both internal organisation and relationships with external partners. All 12 agencies reported that most barriers are not exclusively linked to work with IDPs, but more generally to reproductive health and to the agencies’ general modes of functioning.

Collaboration with partners

Collaboration barriers were among the most prominent. Agencies encounter these when interacting with international partners, local communities or groups in the field. Respondents stressed the difficulties caused by poor coordination of field operations, the lack of common goals and the isolated planning of activities, which often lead to duplication of efforts between partners, and an increased workload. While sharing of tasks and more active communication between all agencies are desired, they are often not possible due to limited resources:

“Collaboration with partners is not always simple because there is a lot of need of communication, of sharing of objectives and this takes a lot of time, money and energy, to achieve collaboration… We have collaboration [with] many partners, but I know it is very heavy to keep… I think [this is] more of a general [type of barrier, not specific to reproductive health of IDPs].” (Medical Advisor, NGO 1)

“…there is so much overlap, fantastic efforts [and] good material, but many apply to so many [other] vulnerable populations as well. … Are they really so different [for] each population? [We need] much more consolidation. There is so much information available, no need to reinvent the wheel.” (Migration Health Manager, Multilateral agency 10)

Other informants emphasised the variety of partners (in type, mandate, objectives of field operations, etc), time constraints affecting programmatic planning, donor trends and competition for the same resources, often resulting in overlapping interventions as obstacles to better coordination.

Joint report writing (eg. inter-agency situation analyses, proposals and assessments) was identified as one of the most successful forms of collaboration, and was said to increase the chances of expanding field operations and enhancing the weight and credibility of inter-agency partnerships in the eyes of other partners and donors:

“I think one of the biggest recommendations … is working closely with your colleague agencies… We’ve been able… to come together and write joint assessments… So the information of what the situation is has been very good. A joint assessment that has all of our [expertise] has a lot more weight… It takes a lot of work and effort but [is] really worth [it].” (Women’s Health Expert, NGO 4)

Other respondents emphasised collaboration by elaborating standards and guidelines, or by sharing tasks between specialised agencies. Respondents felt that such collaboration would stimulate debate between and within agencies, and thus raise awareness of the reproductive health needs of IDPs. Such collaboration helps in shifting agencies’ relationships from competition to partnership, which further helps overcome barriers.

International legal and policy framework

As a policy matter, some conservative national governments and international governmental agencies, whose policies favour cultural, religious or socially defined beliefs and values regarding gender relations, marriage and childbearing, do not see the need for comprehensive reproductive health services; the same applies to humanitarian agencies that are not familiar with reproductive health issues. Services typically left out are family planning, safe abortion and post-abortion care. Although safe abortion generally is regarded as an essential service – especially in cases of rape – the majority of agencies exclude this service because of its politically sensitive nature. Agencies providing post-abortion care only are relatively spared from political controversy related to safe abortion, and treat patients with post-abortion complications as they would treat patients with any other obstetric complication. This also sometimes gives them increased access to patients with HIV and AIDS and sexually transmitted infections, and victims of gender-based violence. In other instances, governments and donors pursue their own agendas and do not pay sufficient attention to reproductive health, limiting agencies’ operational performance and leaving the provision of services to IDPs to the most committed agencies:

“…the international policies… are a major barrier to us… [Especially because of the Global] Gag Rule … we’re not doing abortion care. We’re linked with [name of agency] and part of their mission has been not to try to get any of the PEPFAR ^* and Gag funds. ^† …Out of principle they’re saying… if the Government is going to have this policy and being so restrictive about what we can do, we’re just going to try to work around that. And I think that has created a lot of funding constraints…” (Programme Associate/Reproductive Health, NGO 5)

“…The donor trends decide [what] is the good thing to fund versus the things they ignore, whether it is for political reasons or whether it is because the country has oil and they don’t want to upset the Government… International policies play a role in the barriers.” (Project Manager/Reproductive Health for Refugees, NGO 2)

In terms of legal framework, international recognition of IDPs – along the lines of the UNHCR Convention for Refugees – would greatly facilitate provision of services to IDPs:

“If you are an IDP, it is more complicated to get services, compared to refugees [who] are in a better position because of the [UNHCR] mandate.” (Health Advisor, NGO 9)

“IDPs have no UN convention which would demand their rights be held… [and] recognition of IDPs… The immense volume of IDPs [is] not identified internationally… I’m sure that’s the key.” (Programme Director, NGO 11)

Agencies developed strategies for overcoming these barriers, ranging from choosing carefully a favourable environment for providing reproductive health services to IDPs – sometimes on the margins of national laws – to advocating and lobbying at various levels for reproductive health and IDP-related policies, practices and regulations. Targeting new private donors and combining activities according to prevailing trends were another way of improving agencies’ operational independency and performance. Lobbying at the international level was particularly well reflected in one respondent’s efforts:

“I have proposed to the Government [of a European country], that the [initiative] is presented… to the EU, that they could… in the coming 5–6 months… [advocate the establishment of] a UN convention for IDPs… It has had a formal response from the [Minister for Foreign Affairs]…” (Programme Director, NGO 11)

“… we provide [safe] abortion and treatment of complicated abortion services in places where it’s illegal for local [personnel]. [We] overcome this… by doing all these activities with expatriate staff… [Since] they are international staff, the law is a bit softer on them.” (Sexual and Reproductive Health Advisor, NGO 3)

Mandate and management

The barriers related to agencies’ mandates and philosophy and internal management are closely linked to each other, in the sense that even in cases where reproductive health services for IDPs are explicitly mandated, managerial commitment to providing services to IDPs may remain minimal. Faith-based or conservative values may influence managerial decision-making, and individual preferences among managers can also come into play. Poor awareness among managers can adversely affect perceptions of reproductive health issues – even when these are recognised as being an integral part of primary health care. The implementation of the Minimum Initial Service Package is related to this, and although most respondents are familiar with the package, it is not fully implemented by any agency, either because of its complexity, or the high costs involved.

“We are a Catholic agency, conservative, not progressive in reproductive health terms… We don’t need to have [reproductive health] as a priority, because we’ve so many other things to do.” (Health Advisor, NGO 9)

“It’s not always understood that [reproductive] health should be included from the very beginning, in primary health care… If you don’t do it from the beginning, it is very hard later on to include it… Health is seen as something special or specific, or separate, or it is too expensive… It is not so easy for non-health staff to understand the importance of the issue.” (Migration Health Manager, Multilateral agency 10)

“I don’t think the [Minimum Initial Service Package] is used as a complete package in all situations. People may work rather on their own experience than following the [package]… It’s a continuous awareness-raising matter… We continuously need to resend the message.” (Migration Health Manager, Multilateral agency 10)

In response to such constraints, staff members who are well informed about reproductive health issues and aware of their agency’s weaknesses use non-threatening strategies for overcoming barriers, gradually increasing their efforts to improve the acceptance of reproductive health services and to expand agencies’ mandates to cover broader topics. Proactively engaging the country office management in programme planning, implementation and realistic time management further helps anticipate future needs of the agency. In some cases, IDPs are sent to places where services are known to be available; in other instances, small-scale reproductive health projects are introduced within the agency:

“For example condoms, we cannot distribute them [through our agency] but can tell people where to go to get them.” (Health Advisor, NGO 9)

“We’re trying to start off with little tiny things that are not threatening, whether it’s maternal health [or any other health activity]. Then you can add on things. So this is a… strategy, and it… helps the country office to build its own internal capacity to do good RH programmes, so it makes sense to start adding things on.” (Senior Programme Advisor/Sexual and Reproductive Health, NGO 8)

Priority setting

Prioritisation of other services is closely linked to other barriers, and observed especially in decentralised and multi-sectoral agencies, which may have other priorities than providing comprehensive health services. Reproductive health services may be contrasted with other health services at the primary health care level, which confronts agencies with difficult choices. Typically, agencies prefer to focus on existing strengths:

“… our organisation is multi-sectoral, [and] not specifically focused on health … [Therefore] we have decided to focus more on other issues [than health].” (Programme Director, NGO 4)

One of the mechanisms to overcome this constraint is internal training on health issues, especially among colleagues who do not work on health issues:

“…We try to have internal department staff… included in training, training of new staff, not health staff. We try to train non-health people… We do this at the global scale.” (Migration Health Manager, Multilateral agency 10)

Other respondents emphasised awareness campaigns, cost-benefit analyses, delegation of tasks to partner agencies and increased dialogue with local populations and IDPs themselves. A particularly successful strategy to raise awareness of IDP issues was described as follows:

“What helped the organisation as a whole is, the agency made a very good information campaign in [country]… They followed the diary of somebody who assists these people. Every day it was published through [radio station], so one could follow what happens with IDPs through the person’s interviews. That raised a lot of awareness among the general public, and our agency received more support, thanks to that.” (Migration Health Manager, Multilateral agency 10)

Limitations of the study

Barriers and strategies for overcoming them are likely to be context-specific to some extent, and attempts to generalise from our results should be undertaken with care. Our findings support those of key international authorities on this issue, including the Inter-Agency Global Evaluation 2004.¹ Due to resource constraints the survey had to be carried out in a short period of time, resulting in a low response rate, which is a major limitation of our study. The agencies who were available for interview cannot be assumed to be representative of all the agencies identified. Due to the short time frame it was not possible to include local and national agencies working with IDPs; we acknowledge that the barriers they face may be different from those faced by agencies from the industrialised countries. Our study can however be seen as a starting point for more extensive research, whose focus should encompass national and local agencies in developing countries. Such operational research should be conducted in close collaboration with the agencies, so that its results are likely to help them overcome barriers to providing reproductive health care to IDPs.

Discussion

Despite its limitations, our study provides useful insights into the barriers for the provision of reproductive health services to IDPs and strategies to overcome them. These barriers are often specific to the IDP or reproductive health context, but also, to a considerable extent, relate to more general matters like agencies’ internal organisation and their collaboration with international, national and local partners. This suggests that, while reproductive health and IDP-specific responses are key, improving agency management, collaboration and coordination with partners also plays a central role. Geographical, security and transport constraints were only specified by a few interviewees, which was somewhat surprising.

As IAWG and RHRCC have found, this study reinforces the general perception that the provision of reproductive health services for IDPs is inadequate and highlights ways to address this lack. According to several respondents, national authorities often neglect their responsibility for protecting IDPs, and this is where the international community could strengthen its role as a catalyst for service provision to IDPs. In particular, the Guiding Principles of Internal Displacement,⁴ the Minimum Initial Service Package²⁰ and the Sphere Handbook²⁸ should facilitate responses to reproductive health needs in emergency situations and serve as practical tools for the international health community to provide comprehensive reproductive health services. Nonetheless, these tools can help address IDPs’ reproductive health needs up to certain limits only: in line with the literature our study reveals that even well-informed humanitarian actors rarely implement the Minimum Initial Service Package fully,^1,18 and few agencies recognise that the recommendation to appoint a Reproductive Health Coordinator is fundamental. Such a coordinator, with responsibility for the overall coordination, supervision and integration of reproductive health interventions,²⁰ would be instrumental in facilitating a comprehensive approach by allocating various tasks to the most competent partners. Substantial improvements could be made by a firm commitment to IDP reproductive health issues, and by seeking potential expert partners.

In terms of the agencies’ internal organisation, and the collaboration with international, national and local partners, our findings can be examined in the light of two approaches to improve inter-agency responses in situations of emergency and internal displacement. The Cluster Leads Approach by the Inter-Agency Steering Committee aims to strengthen strategic

IDF camp after earthquake, Islamabad, Pakistan, 2005

field-level coordination, standard-setting, and prioritisation and accountability between partners.²⁹³⁰ The Collaborative Approach, used by four leading European donor organisations, seeks to support the inter-agency arrangements of humanitarian agencies, national governments and donors to meet the challenges of internal displacement, through an effective, accountable and predictable collaboration mechanism.⁷ These approaches have become popular – the United Nations being one of the strongest actors – because they favour divided collaboration across partners, in contrast to one authoritative agency taking the sole responsibility.^7,31 They also support our finding that tackling barriers through internal strengthening and inter-agency collaboration is important. Several respondents recognised that providing comprehensive reproductive health services to IDPs is too challenging for a single agency, and therefore improved collaboration with partners is essential to address the multi-faceted reproductive health needs of IDPs. In practice, each agency could provide the services it is particularly competent at, with the aim of offering comprehensive services for the population at a single location. This would not only decrease individual agencies’ burden to respond to IDPs’ reproductive health needs but would also make the service provision more comprehensive and sustainable.

According to the literature, a major challenge in conflict situations is the lack of specific reproductive health data obtained through standard aid packages.^1,15,36,37 This may not in fact be the most fundamental problem. Our respondents pointed to a rather overwhelming number of reports, assessments and indicators, and to the problem of agencies’ difficulties in sharing these resources. Busza and Lush present an interesting solution, using a conceptual framework for situations of scarce reproductive health data on conflict-affected populations. This systematic approach uses limited, often secondary, data for describing patterns in reproductive health needs of conflict-affected populations, and for planning relevant health services.³⁷ This may interest agencies without the capacity to invest in elaborate information systems and wishing to benefit from partner organisations’ experiences. To maximise its benefits, this framework can be used along with existing reproductive health proxy indicators, introduced by Hynes et al³⁸ and UNICEF/WHO/UNFPA process indicators.³⁹ Respondents referred to a multitude of existing indicators; hence, better mechanisms to share data from these are probably needed rather than more indicators.

A further barrier identified by our interviewees is the harmful competition between agencies. Financial constraints make agencies fight for the same funds in situations where they should be aiming to improve collaboration with partners. Delegation of services to partners could help agencies to save resources and focus on certain priorities, but in reality agencies rather limit collaboration or give up reproductive health service provision to IDPs partially or totally.³¹ The duplication of efforts side-by-side with gaps in service provision are also significant problems: one area or population may be immersed in agencies’ interventions, while another suffers from a total lack of services.¹ Yet another manifestation of competition is found among agencies that claim to be “needs-driven” but hold to their own vision about the best response to IDPs’ needs; inter-agency diversity of values and objectives impede their ability to communicate and work effectively together.⁴⁰ Differences in ideological, cultural and faith-based values within governments and the donor community clearly get reflected in competition between humanitarian agencies. Dependence on government and donor policies is problematic and has had negative effects on agencies’ service provision and coordination activities; for instance, three agencies in our study are based in the US and liable to their government’s funding policies.

Our interviewees tended to think that agencies would perform better if they built strong partnerships based on the needs of IDPs. At field level, this could mean extra efforts to exchange information on programmes offered and populations covered, including but not limited to the geographical location of IDPs and the composition of these populations. While agencies need to improve their collaboration, donors, whether secular or faith-based, should also allow greater flexibility to use funds for a range of reproductive health services, populations and geographical areas.

The absence of an international legal framework that protects IDPs’ rights is the barrier that is most specific to IDPs. According to many respondents, the situation of IDPs compares unfavourably with the situation of refugees. This is supported by the literature, which points out that the Convention relating to the Status of Refugees leaves refugees in a better position than IDPs.^5–7,41 However, several studies have shown that IDPs living in organised settings (e.g. camps) may have a better reproductive health status than local populations;^1,22,38,41 in some cases, interventions in IDP camps have had beneficial effects on the transport infrastructure and economic development of the entire geographic area.⁴⁰ These findings suggest that identifying and registering IDPs would allow them to be provided with health care more systematically, including reproductive health care. An international convention that recognises and protects the rights of IDPs – similar to the one that addresses refugee issues – could become the legal basis, even obligation, for such identification. While only one respondent explicitly identified the absence of an international convention to protect IDPs as a major barrier, we believe that what has helped refugees could be beneficial for IDPs, too. In the meanwhile, there is much room for improvement even without an international IDP convention, as our study has demonstrated.

Recommendations

On the basis of our study, we offer the following recommendations to agencies providing reproductive health care to IDPs and to those intending to do so:

• to raise awareness of reproductive health issues concerning IDPs within their agencies and with partner organisations, including funding agencies,

• to share tasks and expertise among agencies at the local level,

• to strengthen inter-agency coordination and collaboration to save resources and avoid duplication of efforts, and

• to explore the possibility of an international convention to protect the rights of IDPs.

We believe that these steps would reduce the gap between the international community’s commitment to providing reproductive health care to IDPs, and the constraints on doing so faced by humanitarian and relief agencies in the field today.

Acknowledgements

Special thanks to all study participants, for their willingness, time and trust, and to Samantha Guy, Marie Stopes International, for her input into the design of the study.

Notes

* PEPFAR: US President’s Emergency Plan for AIDS Relief.³⁴

† Global Gag Rule: US government policy that prohibits the allocation of family planning funding to international organisations involved in abortion-related activities.³⁵